HM Medical Clinic


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COPERTINA ABSTRACT 300x210:Layout 1 18-11-2009 19:04 Pagina 1 THIRD INTERNATIONAL CONGRESS ON International Institute University of Mekelle National Institute Health Sector Development International Society International Centre for Health Migrants Forlanini Hospital for Migration and Health Anthropological Sciences Dermatological Care for All: Common Diseases for Neglected People ISD Regional Meeting Addis Ababa-Mekele November 24 in Addis Ababa National Institute for Health Migration and Poverty Successive Sessions: November 25-27 in Mekele Ethiopian Embassy Under the Patronage of for info web: · e-mail: [email protected] · [email protected] Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 1 THIRD INTERNATIONAL CONGRESS ON Dermatological Care for All: Common Diseases for Neglected People Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 3 Workalemahu Alemu Mohammed Beyan, Fuad Temam Yeshambel Belyhun Kassahun D Bilcha Mengistu Hiletework Dagnachew Shibeshi Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 5 Epidemiologist - Project "Italian Contribution to the Health Sector Development Programme" Italian Cooperation.

Skin diseases represent one of the most frequent causes of morbidity in Ethiopia, and, since they are often related to household crowding and lack of hygiene – conditions reflecting low socio-economic status – they are considered as important contributors to the health in-equalities. In order to assess the contribution of sex (biological characteristics) and gender (so-cial characteristics) to the skin disease burden, we performed a retrospective analysis of 40,450outpatient and 1,346 inpatient medical records in the Italian Dermatological Centre in Mekelleduring the period 2005-2008. The leading causes of outpatient attendance were eczema(n=9,711), mycosis (n=6,445), pigmentation anomalies (n=4,116), and scabies (n=2,709). Theoverall number of outpatient visits was similar by sex (M:F ratio=1.1), with the highest M:F ra-tios being found for scabies (1.6), while the lowest one were observed for pigmentation anom-alies (0.7). In children (0-5 years), scabies was the leading cause of outpatient attendance(25.4%), showing the highest M:F ratio (1.9). Different patterns were observed for inpatientservices, with scabies being the leading cause of admissions (n=228), followed by eczema(n=169), pyoderma (n=158), leishmaniasis (n=146), and burns (n=79). The number of hospitaladmissions was higher among males (864) than females (482), with an overall M:F ratio of 1.8.
Males had more admissions for all the leading causes, except for burns (M:F ratio=0.9). Sincethese sex- and gender-related differences are dynamic and driven by the interplay of biology,social organization, and health systems, their documentation is crucial for improving service de-livery and for assessing the achievement of the dual goals of improving health status and re-ducing health inequalities. Cost-effective interventions are available to reduce skin diseaseburden and should be implemented in the framework of the health-sector development pro-gram.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 6 Department of Dermatovenereology, Faculty of Medicine, University of Addis Ababa, Addis Ababa (Ethiopia) TUMOROUS RHINOPHYMA IN A 65 YEARS OLD PATIENTS
A 65 years old patient presented at ALERT dermatology hospital with gradually enlarging lesion on the nose of 10 years duration. He noticed mild burning sensation upon sunlight and hot exposure. On physical examination multiple pedunculated overgrowths is seen on thetip of the nose. The skin surface of the lesions is shiny and showed pea u de orange appearance.
Histology of the lesion demonstrates sebaceous hyperplasia confirming the diagnosis of rhino-phyma. Rhinophyma is late stage of roseacea more commonly seen in males than in females.
Big, tumorous and pedunculated lesions are rare. We present this case report supported by clin-ical and histopathological pictures as well as literature reviewed.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 7 Robel Assefa

Leprosy is one of the infectious dermatological diseases important in the developing world.
Ethiopia is one of the countries who has eliminated leprosy (less than one in 10 000 people, WHO).One of the challenges of leprosy treatment is management of leprosy reactions whichcan appear after successful treatment. Though the bacilli are dead, remnant antigens can causeto result in two different types of reactions. Type II leprae reaction (ENL) is a systemic illnesswhich affects the skin, nerves, eyes, testicles & kidneys.
In this case series I report fatal cases of ENL in two ex-leprosy Ethiopian patients who have been effectively treated with multidrug therapy (MDT) and suffered from severe ENL.
I also point on challenges & the way forward in the management of ENL to improve the quality of life and decrease the functional disability of leprosy patients in Ethiopia.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 8 Robel Assefa
Alert Hospital – Addis Ababa (Ethiopia) VOHWINKEL KERATODERMA;

Palmoplantar keratoderma is a group of heterogeneous disorders mainly affecting the pal- moplantar skin. PPK can be Acquired or inherited.
There are specific keratins expressed only on the palmoplantar skin. The genetic defect of which result in PPKs of various types. Besides defect in keratin genes defects in connexions, lori-crin or SLURP can cause PPK.
The inherited PPK is divided in to simple (affecting the palms & soles only), compound (af- fecting the palmoplantar skin & other areas) and syndromic keratoderma in which other organinvolvement derived from the ectoderm.
In this case report I report a 17 years old female Ethiopian with one of the rare PPKs Vo- hwinkel mutilating keratoderma: PPK with deafness.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 9 Increasing People Opportunities (IPO), Perugia (Italy) MAKING DERMATOLOGICAL CARE EFFECTIVE FOR ANKOBER

Community-based primary health care has been widely regarded as the approach most likely to provide remote areas with equitable health care. IPO (Increasing People Opportunities), an Italian non profit making organization together with Ethiopian Ngo AWDA (Ankober WoredaDevelopment Association), Debre Berhan University and local area's authorities have made at-tempts to devise herbal preparations based on indigenous flora in order to integrate them in thelocal health care systems and partially sort out the problem of drug supply.
A preliminary participatory reconnaissance survey of the traditional medicinal plants was con- ducted and the Ankober ethnobotanical traditions were investigated to complement the exhaus-tive research on scientific literature about herbal dermatology and phytotherapeutic approachesto skin conditions. Based on a shortlist of medicinal plants, further researches were undertakento determine how guarantee an adequate protection to endemic species while introducing sus-tainable wild harvesting methods, taking into proper account harvest intensity with relation tosoil erosion and plant regeneration. On the other side, a long-term viable alternative was set bydomestic cultivation with a nursery managed by local farmers. Steam distillation and hydro alcoholic extraction with ethanol as solvent were chosen as methodology of extraction of the plant material on the basis on the in loco reproducibility andthe low level of technology involved. The content of the active plants extracts components wasevaluated to assess the correspondence to the ESCOP or International Pharmacopoeias standards.
The extracts were further assessed for their in vitro efficacy on fungi strains. The safety of the twogalenical preparations containing the extracts was assessed once applied on human skin.
As a result of a positive trend, a laboratory was constructed to serve Ankober community producing simple galenical preparations as a locally prepared alternative for treatment of mycosisand eczema like lesions.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 10 Tebebe Y. Berhan

The World Health Organization (WHO) estimates that approximately 37.2 million peoples are infected in 37 endemic countries with onchocerciasis. Approximately 123 million people live in endemic areas worldwide and therefore, we are affected at risk of infection; more than 99%of those at risk reside in Africa. Periodic mass treatment with Mectizan® (3mg) prevents eyeand skin disease caused by O. volvuls and may also be used to reduce and even to interrupttransmission of the disease depending on the frequency of treatment per year and the geo-graphic extent of the distribution programs.
Over 1 billion people are infected and at risk of Lymphatic Filariasis world wide. The ongoing Malaria Control Program by distribution and increasing the usage of LLIN for more LGAs hascontributed tremendously on the control of transmission of the disease. The onchocerciasiscontrol program of distribution of Mectizan® open a new era on the control and eradicationof Lymphatic Filariasis by distributing Mectizan® (3mg) with a combination of Albendazole®(200mg) make the whole success.
The direct and indirect participation and involvement of Lions Clubs International with its partners contributed immensely on control and elimination of onchocerciasis, in the near futurewith Lymphatic Filariasis. These milestone contribution on neglected diseases certainly willchange the face of tropical countries and play the most significant role in the economic devel-opment of this countries, which heavily affected by these devastating diseases. These undoubt-edly contributed to improve the quality of life in the developing countries.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 11 Mohammed Beyan, Fuad Temam
Department of Dermatovenereology, Faculty of Medicine, Addis Ababa (Ethiopia) SARCOIDOSIS IN A 45 YEARS OLD FEMALE POSING DIAGNOSTIC

Sarcoidosis is a granulomatous systemic condition affecting the skin in about 25% of the cases and may be the initial presentation of the disease. Because of the wide range of skin manifestations of sarcoidosis, a classification dividing them into specific and none specific le-sions has been proposed. Specific lesions are characterized by none caseating granulomas andare present in 9% to 11%. As the number of lymphocytes associated with granulomatouschanges can be variable in conditions such as cutaneous tuberculosis, tuberculoid leprosy, for-eign body granuloma, cutaneous leishmaniasis and sarcoidosis the diagnosis of sarcoidosiscan not be made with certainty on histopathologic grounds alone.
We present a case of sarcoidosis in a 45 years old female Ethiopian patient, who was di- agnosed to have leishmaniasis first and TB later and subsequently, she has been treated with(fluconazole & cryotherapy) and anti TB drug respectively. She didn't show any improvementwhich forced her to come back to the out-patient clinic at ALERT. We reviewed her previous slideof sections of skin tissue and made a diagnosis of Sarcoidosis by establishing clinico-pathologiccorrelation. After the patient has been investigated further by chest x-ray, laboratory examina-tion, and ophthalmologic evaluation strong evidence came out to show bilateral hilar lym-phadenopathy and significantly elevated angiotensin converting enzyme inhibitor. The patienthas been started on systemic prednisolon of 30 mg per os daily and it was tapered by 5 mgafter four weeks following a significant clinical improvement.
History of the patient, clinical findings, chest radiography, and relevant laboratory exami- nation including histopathologic findings will be presented with a review of literature alongwith a clinical picture before and after treatment as well as the histopathologic picture of thepatient.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 12 Andargachew Mulu1,2, Ermias Diro3, Henok Tekleselassie4, Yeshambel Belyhun1,
Belay Anagaw1, Martha Alemayehu1, Aschalew Gelaw1, Fantahun Biadglegne1,
Kasahun Desalegn5, Sisay Yifiru6, Moges Tiruneh1, Afework Kassu1,7,
Takeshi Nishikawa8, Emiko Isogai9

1Department of Microbiology and Parasitology, College of Medicine and Health Sciences, University of Gondar,Ethiopia, 2Institute of Virology, Medical Faculty, University of Leipzig, Germany, 3Department of Internal Med-icine, College of Medicine and Health Sciences, University of Gondar, Ethiopia,4Department of Surgery, Facilityof Medicine, Addis Ababa University, Addis Ababa, Ethiopia, 5Department of Dermatology, College of Medicineand Health Sciences, University of Gondar, Ethiopia, 6Department of Pediatrics and Child Health, College ofMedicine and Health Sciences, University of Gondar, Ethiopia, 7Division of Allergy and Clinical Immunology, De-partment of Medicine, University of Colorado Denver, USA, 8Hokkaido University of Education, Division ofMedicine and Nursing, Sapporo, Japan, 9Department of Disease Control and Molecular Epidemiology HealthSciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido 061-0293, Japan EFFECTS OF ETHIOPIAN MULTIFLORA HONEY ON CANDIDA SPECIES

Background: Oropharyngeal candidiasis is a rising clinical problem in immunosuppressed
patients. The global pandemic of HIV/AIDS and the increase in drug resistant microbial infec-
tions alerts the need to look for alternative treatment options. Although, honey has been re-
ported to have bacteriostatic and bactericidal effects, its antifungal activity has not been well
Objective: To determine the antifungal effect of Ethiopian multiflora honey against Candida
species isolated from oral cavity of HIV infected subjects or AIDS patients
Methods: Oral rinses were obtained from 13 HIV infected patients with different WHO
HIV/AIDS clinical case definitions by asking them to rinse their mouth with 5 ml of normal
saline for 30 seconds and to expectorate the rinse into a sterile container. All the expectorate
fluid was poured to a CHROMagar plates. After 30 seconds, the media were drained and in-
cubated at 37oC for 48 hours. Candida species were identified by conventional microbiological
techniques and polymerase chain reaction. The inhibitory and cidal concentrations of honey
sample on Candida albicans, Candida tropicalis and Candida glabrata were investigated by an
agar dilution technique.
Results: Candida species were isolated from oral rinses of all patients yielding a total of 71
colonies. The dominant species isolated were Candida albicans (41/71) followed by Candida
tropicalis (15/71) and Candida glabrata (9/71). Growth of the Candida species was inhibited
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 13 with complete inhibitory and cidal concentration of 30-40% (v/v) honey. The MIC of the honeyfor all Candida species was not significantly different (P> 0.05). In addition, the honey sampleretained its anticandidal activity after heat treatment; the anticandidal activity of honey wasdecreased by 12.5% after heat treatment, although the difference was not statistically signif-icant (P > 0.05).
Conclusion: Honey has both static and cidal activity against Candida species when tested in
vitro. This supports the existing folkloric practice of using honey to treat oral lesions. Neverthe-
less, clinical evaluation and pharmacological standardization on the effect of honey are crucially
important before using honey as curative agent to oropharyngeal candidiasis.
Keywords: oropharyngeal candidiasis, HIV/AIDS, antifungal effect, honey
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 14 Kassahun D Bilcha
Assistant Professor of Dermatovenereology, Gondar College of Medicine and Health Sciences, Ethiopia MECHANISM OF GENITAL ELEPHANTIASIS
Genital elephantiasis is gross enlargement of the male or female genitalia due to, usually acquired, lack of proper drainage system for the lymph. It is common problem in the tropics usually affecting young and productive age group. Both infectious and non infectious causeshave been identified. Extensive literature review, though not adequate, and clinical experienceis used to revisit this condition. The clinical picture of genital elephantiasis is primarily determined by the lymphatic chan- nels that are destroyed by the condition which intern depends on the primary site of affectionfrom which lymph is being drained. The size of enlargement is entirely the matter of time andpartly determined by the severity of the primary condition. Once occurred lymphatic edema ofthe genitalia is irreversible and progressive. Complications could occur. Medical treatments donot work and surgery has been tried with limited success.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 15 Kassahun D Bilcha
Assistant Professor of Dermatovenereology, Gondar College of Medicine and Health Sciences, Ethiopia SHOE DERMATITIS IN ETHIOPIA
Dermatitis affecting the feet is an important cause of morbidity and disability. Even though endogenous, causes are not rare; it is usually allergic contact dermatitis arising from the shoe. Either the lining of the shoe or the socks could cause contact dermatitis. Leather dyes,rubber accelerators and antioxidants as well as shoe glue are frequently mentioned causes. The cause of suspected allergic contact dermatitis from the shoe could be easily identified with patch testing using the additional shoe series. In Ethiopia, where standard patch testseries are not well-used, we tried to look for the frequency of shoe dermatitis in eczema pa-tients, clinical patterns and the possible causes. Contact Dermatitis affecting the feet accountsmore than 60% of all cases of exogenous eczema. About half of them are patch test positiveeither for the standard battery or for any of the components of the shoe. Nearly 95% of the allergens arise from the shoe, principally the glue of the shoe and the dorsa of the feet are most affected. Identifying possible cause of shoe dermatitis and subse-quent proper management and prevention should be well addressed for patients having footdermatitis. Additional shoe series allergens for patch testing should be introduced, apart formthe standards series, in the country.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 16 Department of Dermatovenerology, Alert Hospital, Addis Ababa (Ethiopia) A MOBILE COMMUNITY DERMATOLOGIC CLINIC IN ANKOBER

Introduction. In Ethiopia, most of the rural area's population do not benefit by dermatological
care and dermatological diseases are often ineffectively managed. People seek frequently cheap
treatment by inadequate healthcare providers, using home made remedies and buying poten-
tially dangerous non-prescribed drugs. In two previous epidemiogical work (not yet published)
we have assessed the real frequency of dermatological problems in children in two rural areas
of Ethiopia (Debre Markos and Ankober woreda). In both areas we have found an high
incidence of skin diseases.
Objective. To assess the common prevalent skin disease in Ankober woreda.
Methods and Material. The staff (one dermatologist and two Community Health Workers)
reached the Health stations (Gorobela and Aliu Amba) bimonthly to perform the medical ex-
aminations. People were informed by a loudspeaker transmitted message about the presence
of the visiting staff in the next days. People arrived at the Health Station very early in the morn-
ing, usually by foot or, only in case of particularly severe diseases, transported in a rudimental
stretcher, the flow of people continued all day.
The visits took place from 8.30 a.m. till 6 p.m. and about 100 clients were meanly visited during each day visits between new cases and follow ups. The dermatologist performed alsoulcer and lesion medications and some minor ablation, like in the case of painful plantar footwarts.
Results and Discussion. During the first 4 months of activity we have found many derma-
tologic diseases, 39% of them were of infectious origin. The most frequent of them were fungal
infections, but also leishmaniasis, leprosy, scabies, pyoderma, etc. Atopic dermatitis and eczema
related diseases were also very frequent. During the visits the doctor highlighted the peculiar
aspects of the different dermatologic diseases and lesions, carrying out also the educational
and training process of the common skin problems to the Community Health Workers.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 17 Regional Dermatology Training Centre, Moshi (Tanzania) TEACHING DERMATOLOGY IN NEW PLACES
Whilst it is a privilege and an honour to be given the opportunity to teach our wonderful specialty in places far from home, it can be daunting. I frequently hear concerns; ex- pressed will I be relevant, will the treatments I suggest be available? The aim of this presen-tation is to share some personal experiences and approaches that I have taken when faced withteaching in a new environment. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 18 Cottolengo Mission Hospital – Chaaria – 60200 Meru (Kenya) COMMON DERMATOLOGICAL PROBLEMS IN CHAARIA
To diagnose a skin condition is always very difficult for a physician working in a rural hospital in Africa. First of all the diseases on black skin are often different from the normal presen- tations learnt during our University training. Secondly, we are not dermatologists and it is verydifficult to find one in a rural setting like the one where we operate in Chaaria.
Many times we end up giving too much of steroids to everybody, even when steroids are not indicated. On the other hand we can miss many diagnosis because of lack of facilities (skinbiopsy is expensive).
In this presentation I just wish to show some of the most challenging cases I have found in my personal practice.
Pemphygoid is certainly a difficult diagnosis to make. Sometimes even a generalized scabies can pose a problem of differential diagnosis with other generalized itchy rush.
Above all in HIV people HSV II can cause very destructive condition, but you must be very careful also to perineal skin destruction secondary to Crohn disease, as we finally discoveredin one patient after we performed a colonscopy.
Many times our diagnosis relies on tele-consultation and advice from specialists abroad.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 19 Professor in Dermatology and Biochemistry, Berlin (Germany) ALKYLPHOSPHOCHOLINES AS SYSTEMIC THERAPY IN LEISHMANIASIS
Leishmaniasis is a clinically heterogeneous group of diseases, caused by infection with pro- tozoa of the genus Leishmania. The aggressiveness of the individual species, their organ preference and the host immune status determine the course of the disease. WHO data esti-mates that leishmaniasis results in 2 million new cases a year, over 12 million people are cur-rently infected worldwide, and approximately 60,000 patients die annually. Currenttherapeutical strategies are based on chemotherapy, which relies on few drugs. Pentavalent an-timony preparations have been the standard of antileishmanial therapy for over 70 years withsecond line strategies used in cases of antimonial failure., like liposomal formulations of am-photericin B, oral ketoconazole or itraconazole, as well as topical paromomycin sulphate, localheat, freezing with liquid nitrogen, or photodynamic therapy. Recently miltefosine (hexade-cylphosphocholine) has been introduced as systemic antileishmanial therapy. The mechanismof action of this orally bioavailable phospholipid analogue in leishmaniasis is not known atpresent. Miltefosine was originally developed as an antineoplastic agent. Chemically, it is a syn-thetic alkylphosphocholine which can be easily produced by a low cost 2-step synthesis. It isnot only directly toxic for Leishmania species, but it was demonstrated that miltefosine en-hances an immunologic antileishmanial reaction in host cells, like macrophages. The compoundis highly effective against most Leishmania species, including those that cause cutaneous dis-ease, achieving over 90% cure in phase II and phase III trails.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 20 Regional Dermatology Training Centre, Moshi (Tanzania) HUMAN CAPACITY BUILDING FOR DERMATOLOGY

Skin diseases constitute in general throughout sub-Saharan Africa about30% of diseases encountered. In many countries skin disorders are among the top five most common causes of morbidity and disability at Primary Health Care (PHC) level.
Looking at the currently available human resource situation from a sub-Saharan perspective the resources available for dermatologic services seem to be completely out-of-balance and incrisis. Practically about 90% of skin disease are firstly seen only by auxiliary health workers andpara-medicals with minimal training and knowledge and who are working with limited re-sources and under unfavourable environmental conditions.
To meet these service deprivation sub-Saharan Africa should build the dermatologic and sexual health care systems that are most effective within the context of their local culturesand resources by initially emphasizing the training on appropriate heath workers', whose train-ing is most responsive to local needs at lowest possible and acceptable social and economiccost. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 21 Department of Dermatovenereology, Faculty of Medicine, Addis Ababa University, Addis Ababa (Ethiopia) EVALUATION OF HANIFIN AND RAJKA ATOPIC ECZEMA DIAGNOSTIC

Background. Different atopic eczema diagnostic guidelines have been proposed for the di-
agnosis of atopic eczema. But the Hanifin and Rajka major and minor criteria seem to have got
a better acceptance internationally. The aim of this study is to select those minor criteria which
are most relevant to the Ethiopian situation, and eventually propose them to be used as a
standard in Ethiopia.
Methods Using the Hanifin and Rajka (HR) atopic eczema diagnostic guidelines as a gold
standard, a total of 119 atopic eczema patients were selected from the diagnostic clinic of
ALERT hospital. Sensitivities to diagnose atopic eczema were calculated for six subgroups,
formed by serially reducing increasing number of minor criteria from the gold standard.
Results. When seven and twelve minor criteria are reduced from the Hanifin and Rajka atopic
eczema diagnostic guidelines the sensitivities to detect atopic eczema case were 96.64% and
86.55% respectively. When further criteria were reduced the sensitivities dropped down sig-
Conclusions Only nine minor criteria (itching while sweating, course influenced by environ-
mental factors/emotional stress, Dennie-Morgan infraorbital folds, recurrent conjunctivitis, hand
dermatitis, foot dermatitis,white demographismus, facial erythema and pityriais alba) are the
most relevant criteria for the diagnosis of atopic eczema in Ethiopia. Xerosis can be taken as
one major criterion.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 22 Center for Research and Training in Skin Diseases and Leprosy, Teheran University of Medical Sciences, Teheran (Iran) SKIN DISEASES: A PUBLIC HEALTH PERSPECTIVE
Despite the differences in types and distribution of various skin diseases and dermatological conditions among human populations, they are considered as one of the most common health problems. Besides the high prevalence of skin diseases, the associated burden of diseaseof cutaneous diseases plays a crucial role in their public health significance.
In this presentation, the author tries to briefly review the influence of epidemiological trans- formation on the prevalence of skin diseases; the individual, familial and social burden of thesediseases; and the potential role of public health programs and interventions in preventing cer-tain skin diseases.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 23 Center for Research and Training in Skin Diseases and Leprosy, Teheran University of Medical Sciences, Teheran (Iran) CUTANEOUS LEISHMANIASIS IN IRAN
Cutaneous leishmaniasis constitutes a spectrum of clinical manifestations which are caused by intracellular protozoa of genus Leishmania. It exists in 90 countries in the world, mostly developing ones. More than 300 million people are at risk of infection and the incidence rateof the disease is estimated about 1-1.5 million new cases each year.
Iran is endemic for Old World cutaneous leishmaniasis. Almost all cases of cutaneous leish- maniasis are caused by either Leishmania tropica or L. major and it is a major health problemin many areas of Iran.
Through this presentation, the author provides a brief description of the current condition of cutaneous leishmaniasis including what has been done to diagnose, prevent and treat thisdisease in Iran.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 24 Sidney Klaus

Skin diseases have only recently been recognized as a major public health problem in developing countries in sub-Saharan Africa; it has been estimated that between 6 and 24% of the total number of visits to primary health care centers are the result of skin complaints. These problemsare now recognized to be among the most frequent causes of morbidity, especially in children andin those infected with HIV. Many of these diseases cause significant disabilities, with serious socialand economic consequences.
People living in rural areas on the eastern flank of sub-Saharan Africa in Tanzania and Ethiopia appear to be especially at risk: a study in Tanzania revealed that 34.7% of villagers hadone or more skin diseases and a survey of randomly selected households in southwesternEthiopia found that 67% of the householders had significant skin disease. Unfortunately it is the children in these areas who seem to bear even a greater burden of these problems. A study of 112 children living in rural Ethiopia found that 80.4% had one or more skindiseases, and a survey of 304 Ethiopian children, examined soon after they immigrated to Israel,showed that 65% were infested with head lice, 39% with body lice, and 10% with scabies.
In addition to the base-line level of skin disorders a new wave of problem emerged along with the HIV/AIDS epidemic. A study of 218 HIV positive Africans indicated that 84% had evidence ofskin manifestations of their illness, and it is estimated that 90% of persons living with HIV/AIDSwill develop skin problems at some point during the course of their disease. These studies suggest that the majority of people living in rural areas in the eastern region of sub-Saharan Africa are in urgent need of appropriate and adequate management of their skinproblems. Approaches leading to a resolution of these problems are complex.
One traditional approach has been through the recruitment of volunteers –often experienced dermatologists—to staff clinics in rural areas and to provide first-line care. Unfortunately thesevolunteers generally remain in the field for only short periods of time, returning to their homeswithin a few weeks or months. While this approach has proven useful for the short term, it doesnot lead to a system of skin care that is sustainable. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 25 A second approach has been the through the establishment of post- graduate dermatology training programs at African medical schools and regional dermatology centers. Unfortunately rel-atively few dermatologists can be trained at any one time, and it is likely that a serious shortageof trained dermatologists still will exist for next few decades or longer. A third approach (the subjectof this proposal), is through the establishment of programs to provide short educational coursesfor primary health workers. Primary health workers in rural areas generally carry the responsibility for the care and man- agement of dermatology disorders. However, many of these workers receive only minimal trainingabout skin diseases and are unable to appropriately diagnose or treat common skin diseases. (Astudy of 2720 patients with skin diseases seen at a rural heath clinic in Ethiopia reported that90% of these cases were misdiagnosed and mismanaged). Inappropriate care often results in moreserious medical problems and/or wastage of both household resources and medical supplies. Preliminary experience indicates that a short training program for general health care workers on the diagnosis and management of common skin diseases will markedly improve the basic der-matological abilities of the health care workers targeted. A pre-course assessment for participantsof a one-day training course offered to 400 health care workers in Bamako, Mali showed that theregistrants' knowledge about skin diseases was scanty and that their practice was modest. How-ever, following a one day series of lectures, a post-course assessment found that the proportionof appropriate diagnoses and treatments rose from 42% to 81%, and that prescription costs werereduced by 25%. It is likely that improvements such as these will be sustainable for years to come.
The curriculum will be aimed at the diagnosis and treatment of common disorders; it is esti- mated that 60 to 90% of all skin disorders in these areas are caused by only 10 conditions, thusa short course aimed at a relatively few diseases should be effective. In addition the content ofeach course will be tailored to the specific region to be visited. Most of the curriculum will concern common infections and inflammations of the skin, such as pyodermas, superficial mycoses, viral disorders, problems associated with HIV/AIDS, infestations(scabies, lice and fleas), and various of forms of dermatitis. Each session will also include a questionand answer period, time for case presentations by participants, and pre- and post- tests to assessthe course's effectiveness.
Educational materials will be provided free of charge to participants; these will include lam- inated cards of common tropical skin disorders (provided by the American Academy of Derma-tology) and a text, Common Skin Diseases in Africa, by van Hees and Naafs.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 26 Sidney Klaus

Cutaneous leishmaniasis is a disorder caused by the invasion into the skin of intracellular protozoan parasites belonging to the genus Leishmania.The disease is transmitted by the bite of female phlebotomine sand flies, and usually manifests as a papule, plaque or ulcer. Generally fewer than 100 parasites are inoculated by a single bite, although occasionally the number may reach as high as a thousand or more. During the bite, the sand fly severs skincapillaries and parasites, along with various components of sand fly saliva, are deposited in asmall pool of blood within the dermis. Less than an hour after the bite, a robust inflammatory response gathers, consisting of neutrophils and macrophages. (Natural killer cells, eosinophils, mast cells, Langerhans cellsand dermal dendritic cells also take part in this round of early inflammation.) Many of the promastigotes deposited by the sand fly are opsonized by serum complement and killed by complement-mediated lysis. However many of the remaining viable parasites be-come rapidly engulfed by neutrophils which collected within a few hours around the bite site.
The parasites phagocytosed by neutrophils may remain alive inside these cells for five days ormore.
However the neutrophils that have engulfed parasites usually undergo apoptosis, which re- leases the parasites into the dermis and these parasites now become targets of a second roundof phagocytosis by macrophages. Once the parasites enter the macrophages they transform intoamastigotes, and become enclosed in modified lysosomal vacuoles. Here they become targetsfor the host's adaptive immune response. Because the neutrophils, by their initial phagocytosis of the promastigotes, serve to promote the entry of the parasites into host macrophages this sequence of events has been termed the"Trojan Horse" model. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 27 Sidney Klaus
Onchocerciasis is an infection with a filarial nematode which causes a variety of skin prob- lems, including sever pruritus, lichenified dermatitis, cutaneous atrophy and depigmenta- tion. The disease, found in 35 countries in tropical areas of the world, is estimated today toaffect more than 37 million people, a number much larger than previously believed, and ap-proximately 90 million people are currently at risk in sub-Saharan Africa.
Suramin, a drug initially used to treat onchocerciasis, was administered intravenously which limited its use and diethylcarbamazine (DEC) which was an effective microfilaricidal, oftencaused sev ere systemic reactions and had to be given repeatedly. In 1982 a new drug, iver-mectin (IVM) was introduced which was directed at elimination of microfilaria; unfortunatelyit doesn't eliminate adult worms, and needs to be re-administered every 4 to 6 months for op-timal effect. More recently there has been concern that repeated ivermectin doses may leadto emerging resistence to the drug.
Within the past few years, a new approach to the therapy of this disease has been initiated, in which 100 to 200 mg/day of doxycycline is administered for a 4 to 6 week period. Resultsof these trials have shown a reduction of >50% of microfilaria.
The targets of this approach to treatment are rickettsia-like endosymbiotic bacteria which infest the microfilaria. These organisms, known as Wolbachia, have been shown to be essentialfor both worm survival and fertility.
Currently IVM continues to be the drug of choice for mass treatments of onchocerciasis in areas of high incidence; but the addition of doxycycline is now being tried in patients who livein areas of low transmission. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 28 Adane Koster
Department of Dermatovenereology, University of Addis Ababa, Addis Ababa (Ethiopia) MULTICENTRIC RETICULOHISTIOCYTOSIS (MRH) – A CASE REPORT
Multicentric reticulohistiocytosis (MRH) is an uncommon disorder but has been observed in more than 100 individuals reported up to 1990, with the purely cutaneous forms seen in more than 50 patients. Caucasians are affected in more than 85 percent of cases, (Fitz-patrick's 2008 DIGM) A 40 years old man from South West Ethiopia presented at ALERT Hospital with pruritic papulonodular lesions of 3 years duration. The lesion initially started on the face & progressivelyinvolving the ear, neck, trunk, upper & lower extremities. The patient is worked up & on followup. We discuss the clinicopathologic correlation with review of literature.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 29 Morrone A, Maiani E, Dassoni F, Calcaterra R, Fazio R, Valenzano MC,
Franco G, Gebre Ab B

National Institute for Migration, Health and Poverty (NIHMP), Rome (Italy) Tigray Health Bureau CONNECTIVE TISSUE DISEASES IN DARK SKIN PEOPLE:

Objective. Important differences in disease manifestations, severity of disease, and disease
outcomes between different ethnic groups have been well established in many diseases.
Nevertheless, there have been few studies of connective tissue diseases in Africa.
Methods. We analyzed the cases of connective tissue diseases observed at the Italian Derma-
tological Centre (IDC) in Mekele, capital of Tigray, the northern region of Ethiopia, between Jan-
uary 2005 and August 2009. During the medical examinations doctors collect anagraphic and
health information; clinical diagnoses have been classified by ICD-9-CM system. Clinical eva-
lutation, if necessary, was supported by blood, instrumental, histological examinations.
Results. In the time range of our study 48,428 patients have been submitted to a first visit in
IDH; 46,874 (96,8%) were outpatients and 1,554 (3,2%) were inpatients.
The records revealed 225 patients (0,46%) affected by connective tissue diseases.
134 of them (59,5%) were lupus erythematosus (5 systemic form, 129 discoid form; medium
age:24,5 years old); 88 (39,1%) were scleroderma (medium age: 24,5 years old). We observed
only 3 cases of dermatomyositis (1,3%), (medium age: 44,3 years old). All the patients affected
by connective tissue diseases were treated in our Hospital.
Conclusion. Connective tissue diseases are more frequent in brown skin population.
Discoid lupus is commoner in dark skin people than systemic form. Skin lesions are influenced
by environmental triggers such as ultraviolet light, temperature, and chemical stresses.
Scleroderma is known to occur in all populations. It has been observed difference among sub-
jects from different ethnic backgrounds. Data from Literature suggest a putative role of genetic
and geographical factors in the ethiopatogenesis of the disease, that could explain the higher
incidence of Scleroderma in pigmented skin people versus light skin people. Dermatomyositis
is roughly ten times more common in dark skin people that live in Africa than in the light skin
population of the Transvaal. Childhood forms of the disease appear to be commoner in light
skin than in deeply pigmented skin.
In our study we observed that skin lesions of discoid lupus are more severe in blacks than in
whites. Squamous cell carcinoma (SCC) often arose on chronic skin lesions.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 30 Also cutaneous and systemic involvement in scleroderma were more severe in blacks than inwhites, with a bad prognosis.
Connective tissue diseases in Ethiopia are probably underestimated; much of this populationdoes not have access to dermatological specialists, which may result in the under-diagnosis ofthese diseases. Public education, and in particular education of community health workers, is important to in-crease preventive strategies and easier access to health care. 1: Tikly M, Navarra SV. Lupus in the developing world – is it any different? Best Pract Res Clin Rheumatol. 2008Aug;22(4):643-55.
2: Toumi S, Ghnaya H, Braham A, Harrabi I, Laouani-Kechrid C; Groupe tunisien d'étude des myosites inflam-matoires. Polymyositis and dermatomyositis in adults. Tunisian multicentre study]. Rev Med Interne. 2009Sep;30(9):747-53. 3: Adelowo OO, Oguntona S. Scleroderma (systemic sclerosis) among Nigerians. Clin Rheumatol. 2009Sep;28(9):1121-5.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 31 A.Morrone, T.D'Arca, M.Di Stefano, M.Diku, C.Germelli, D.Maggio, E.Maiani, R.Mar-
rone, V.Padovese, C.Pajno, E.Rodriguez, M.C.Segneri, G.Troia

National Institute for Migration, Health and Poverty (NIHMP), Rome (Italy) HEALTH AND MIGRATION IN THE MEDITERRANEAN SEA:

Objective. Immigration in Italy is an increasing phenomenon. Thousands of migrants try to
enter Italy and other European nations each year via Lampedusa, crossing the Mediterranean
Sea by boat and risking their lives to reach Europe. During the last 5 years the migrants have
come to Lampedusa rose from 8.800 in 2005 to a number of 31,190 in 2008.
Methods. Since 11th August 2008 a group of specialists (Dermatologists, Infectious Disesase
Specialists, Gynaecologists, Anthropologists, Psychologists) from National Institute for Health
Migration and Poverty (NIHMP) has been working in Lampedusa island both on molo and in
CPSA (Center of First Aid and Reception).
At the moment of landings, migrants are submitted to screening to identify sensitive situations,
as infectious and ecto-parasitical diseases, pregnancies and acute post-traumatic stress con-
After police identification, specialists provide to more accurate clinical evalutations.
During the medical examinations doctors collect anagraphic (country of origin; period, cost
and itinerary of the travel; education; reason for the trip) and health information; clinical di-
agnoses have been classified by ICD-9-CM system.
Results. Since 11th August 2008 to October 2009, 17,470 persons arrived in Lampedusa (81%
men, 11% women, 8% minors). Most migrants come from Nigeria, Tunisia, Somalia, Eritrea,
and Ghana. Most minors come from Egypt.
The triage on molo showed 0,5% conditions of hypothermia especially during winter, and 70%
of dehydration during the summer. We observed 2 deaths due to hypothermia on January
Dermatological and infectivological examinations highlighted: 15% eczema; 8% common
upper respiratory tract infections and chilling syndromes caused by bad travel conditions; 1,5%
scabies and pediculosis, especially among people who had been in Libyan prisons; 1,2% fol-
liculitis and foruncolosis; 1% viral warts; 0,5% Herpes Simplex; 0,6% superficial mycosis; 0,6%
wounds, caused both by traumatic events during the trip and by beating and torture inflicted
in Libyan prisons; 0,3% burns, caused by prolonged contact of the skin with the fuel on the
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 32 boat. We also observed 2 cases of nodal tubercolosis, 3 cases of pulmonary tubercolosis and
1 case of Leishmaniasis.
Gynaecological examinations showed 12% pregnancies, especially among Nigerian women.
Some of them are forced into prostitution in order to continue the trip due to scarce economic
Most of these women were between the 8 and 12 weeks' period of gestation; in a low per-
centage of cases observed pregnancies were within the 32-36 weeks' period of gestation.
Conclusion. Our study represents the first analysis carried out with health scientific method-
ology with a population of migrants immediately after their entry into our country.
These data show that migrants observed in Lampedusa, despite the difficulties of the
journey, are in good general health conditions.
Nevertheless, the inequities of our societies organization and social stratification determine
differential access to and utilization of health care, with consequences for the promotion of mi-
grants' health. Access to health care for vulnerable migrants highlights the human rights ar-
guments in support of making these services available. So in our opinion, it's very important,
both for migrants and for the society in which they live, guarantee the possibility to have easy
access to health care system.
Fortex EU, II Rapporto missione tecnica in Libia 28/05/07-05/06/07, citato in Fortress Europe, 2008, Fuga da
Tripoli. Rapporto sulle condizioni dei migranti di transito in Libia, su
ISTAT, Italia in cifre. Popolazione 2009
Aldo Morrone. Lampedusa, gateway to Europe. A dream to survive. Rome. Ed. Magi 2009.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 33 Morrone A, Maiani E, Dassoni F, Gebre Ab B
National Institute for Migration, Health and Poverty (NIHMP), Rome (Italy) Tigray Health Bureau CUTANEOUS ULCERS IN DEVELOPING COUNTRIES: THE EXPERIENCE

Objective. Cutaneous Ulcers (CU) are a major issue for public healthcare systems in devel-
oping countries, a cause of mortality or of loss of working capability in rural populations.
Cutaneous pathologies, and especially CU, in these countries, are often treated by traditional
healers with herbal medicine and with little effect so they degenerate, in time, into a deeper
wider and harder to eradicate disease.
For such a reason, CUs are often hidden, resulting into social isolation of affected individuals.
Therefore, access to health structures of patients affected by CU in developing countries is
strongly limited. Such a result is also due to uncomfortable socio-economic conditions.
Epidemiological data on the prevalence and the etiology of CU in these countries are generally
poor, making the analysis of the disease even more difficult.
Methods. Patients' anagraphic, and clinical data have been collected between January 2005
and August 2009 at the Italian Dermatological Centre (IDC) of Mekele (Tigray, Ethiopia). Di-
agnoses were classified on the basis of the ICD-9-CM system. Hematochemical, instrumental,
cytological, histological and cultural lab tests were performed when needed.
Results. In the time range of our study 48,428 patients were examined and 1,554 (3.2%)
were admitted in the hospital due to serous clinical conditions. A total of 1,301 CU were ob-
served among patients whose age range was from 4 months and 86 years (average age of 28
As many as 850 of the examined CU (65.3%) were infectious (deriving tuberculosis, leishma-
niasis, osteomielitis, leprosy, impetigo, tropical ulcers, filariasis or sexually transmitted diseases);
275 (21,13%) were related to burns, and 187 (14,37%) were consequence of different etiolo-
gies (cutaneous neoplasia, traumatic injuries, vasculopathies, diabetic and decubitus ulcers,
vasculitic diseases).
Conclusion. The main causes of the observed CU in developing countries are infectious, trau-
mas, burns and diabetes. Whereas venous ulcers, that are the majority of CUs in developed
countries, show low prevalence.
Activity data related to the IDC (Mekele) basically confirm those from the Medical Literature.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 34 The fact that most of CU in developing countries are not of vascular nature implies the needfor checking whether CUs hide one or more complex pathologies of infectious nature (such astuberculosis or HIV) or neoplastic.
To promote an early diagnosis of these injuries, public health interventions have to be properlyplanned, especially in rural areas, including training of community health workers in nursingassistance to achieve an accurate and constant handling of CUs and to facilitate the access ofpatients to the healthcare system.
1: Ebenso J, Muyiwa LT, Ebenso BE. Self care groups and ulcer prevention in Okegbala, Nigeria. Lepr Rev. 2009Jun;80(2):187-96. 2: Senior K. Buruli ulcer: dare we continue to ignore it? Lancet Infect Dis. 2009 May;9(5):273. 3: Abbas ZG, Lutale JK, Archibald LK. Diabetic foot ulcers and ethnicity in Tanzania: a contrast between Africanand Asian populations. Int Wound J. 2009 Apr;6(2):124-31. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 35 Morrone A, Pocaterra D, Pajno C, Maiani E, Marrone R, Dassoni F,
Padovese V, Gebre Ab B

National Institute for Migration, Health and Poverty (NIHMP), Rome (Italy) Tigray Health Bureau DERMATOLOGICAL DISORDERS ASSOCIATED WITH HIV INFECTION:

Objective. Sub-Saharan Africa, has the highest incidence of HIVAIDS infection in the world. Lack
of access to necessary antiretroviral therapy leads to the increased presence of advanced AIDS
and severe pathological conditions related to the infection. The skin represents a sensible indicator
of HIV infection and multiple skin disorder are part of the list established from WHO for the
staging of HIV/AIDS.
Methods. We report our experience at the Italian Dermatological Centre (IDC) in Mekele, Tigray,
the northern most regional state in Ethiopia.
Results. From January 2005 to August 2009, 1,814 HIV positive patients have been examined
with related skin-disorders.
Commonest alterations we recorded included impetigo, dermatophytosis, viral warts and mollus-
cum contagiosus. Atypical clinical presentations (extensive distribution of the skin lesions or pres-
ence of multiple infections in the same patient) represented HIV indicator. Papular Pruritic Eruption
(PPE) represented an important role in the early detection of HIV infection and one of the most
common symptoms encountered in patients with HIV. Investigations for STIs showed high inci-
dence in HIV patients and, in our experience, genital warts represented the commonest.
Conclusion. IDC, in collaboration with the Italian Cooperation-HSPD, Tigray Regional Health
Bureau and Tigray Medical Association is leading an operational research (OR) to spread infor-
mation about the strong relation between HIV infection and skin disorders. The aim of this project
is to improve diagnosis and management skill of peripheral health workers on common skin con-
dition related to HIV/AIDS. We believe in the importance of spreading this dermatological skill to
permit early detection and diagnosis of HIV infection. For this reason, as part of the OR, we are
teaching dermatological discipline in multiple district of Tigray region. Early diagnosis represents
one of the aims to decrease mortality HIV-related.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 36 1: Annam V, Yelikar BR, Inamadar AC, Palit A. Histopathological study of pruritic papular eruptions in HIV-in-fected patients in relationship with CD4, CD8 counts. Indian J Pathol Microbiol. 2009 Jul-Sep;52(3):321-4.
2: Panya MF, Mgonda YM, Massawe AW. The pattern of mucocutaneous disorders in HIV-infected children at-tending care and treatment centres in Dar es Salaam, Tanzania. BMC Public Health. 2009 Jul 14;9:234. 3: Mehta V, Balachandran C, Rao R, Dil SK, Indusri L. Diffuse cutaneous leishmaniasis in HIV. Dermatol OnlineJ. 2009 Apr 15;15(4):9 Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 37 Morrone A, Dassoni F, Maiani E, Marrone L, Padovese V, Pajno C, Gebre Ab B.
National Institute for Migration, Health and Poverty (NIHMP), Rome (Italy) Tigray Health Bureau LEISHMANIASIS IN TIGRAY: OUR EXPERIENCE
Objective. Leishmaniasis is a worldwide disease, considered to be endemic in 88 countries,
72 of which are developing. In Ethiopia, the disease is found in the rural highlands and the in-
cidence of Leishmania/HIV co-infection is increasing. Current WHO reports estimate that 350
million people worldwide are at risk, with a yearly global incidence of 1—1.5 million for cu-
taneous leishmaniasis (CL) and 500 000 for visceral leishmaniasis.
Although some recent studies on CL and mucocutaneous leishmaniasis (MCL) have been car-
ried out in Ethiopia, there is still incomplete information on the disease's epidemiology in Tigray
and there are no reports from this region, as no surveillance system is yet in place. Still now
specific treatments are not available in the country and many people refer to the hospital when
the illness is in a very late stage, after trying traditional medicine.
Methods. We performed a retrospective analysis of clinical records of patients observed at the
Italian Dermatological Centre (IDC) in Mekele, capital of Tigray, the northern region of Ethiopia,
between January 2005 and January 2009, aimed to assess the prevalence of cutaneous (CL)
and muco-cutaneous leishmaniasis (MCL). During the medical examinations doctors collected
anagraphic and health information; clinical diagnoses have been classified by ICD-9-CM sys-
Lesion aspirates and biopsy tissue were obtained from each patient. All specimens were col-
lected and assayed separately, including multiple specimens from the same patient. Parasito-
logical diagnosis was principally based on direct microscopic observation of Giemsa-stained slit
smears obtained by fine needle aspiration (FNA). The aspirates were used to prepare smears,
which showed a rich population of inflammatory cells, predominantly lymphocytes and histi-
ocytes, and epithelioid cell granulomas. Amastigote forms of Leishmania were noted on the
smears. Biopsy samples were obtained from the border of the lesion using a disposable 5mm
punch. Tissue sections were stained with haematoxylin-eosin (HE) and submitted for
histopathological examination.
Results. We observed 471 cases of CL/MCL (1,74% of total visits). The male to female ratio
was 2.5:1 (P>0,005); the mean age was 23.7 years and 60% of patients was in the age
bracket between 15 and 44 years 28% of patients were children under 14 years of age. 86%
had Localized Cutaneous Leishmaniasis (LCL) and 11% Mucocutaneous Leishmaniasis (MCL).
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 38 Conclusion. In Tigray, the patients' clinical profiles, age, duration of illness, number of lesions,
distribution, morphology, progression and major clinical types of the disease were similar to
those seen in other countries.
There are many possible treatments but all the specific and effective ones are not available in
the country, thus people seek for traditional medicine; this is leading to disfiguring and func-
tional impairment of the affected parts of the body (usually face and extremities). Moreover,
people with Leishmania/HIV coinfection need multiple cycles of therapy, as the disease has
chronic and relapsing course in this patients, and possible shifting to the life-threatening vis-
ceral leishmaniasis.
Padovese V, Terranova M, Toma L, Barnabas GA, Morrone A. Cutaneous and mucocutaneous leishmaniasis inTigray, northern Ethiopia: clinical aspects and therapeutic concerns. Trans R Soc Trop Med Hyg. 2009Jul;103(7):707-11. Accorsi S, Barnabas GA, Farese P, Padovese V, Terranova M, Racalbuto V, Morrone A. Skin disorders and diseaseprofile of poverty: analysis of medical records in Tigray, northern Ethiopia, 2005-2007. Trans R Soc Trop MedHyg. 2009 May;103(5):469-75. Bern C, Maguire JH, Alvar J. Complexities of assessing the disease burden attributable to leishmaniasis. PLoSNegl Trop Dis. 2008;2(10):e313. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 39 Morrone A, Dassoni F, Maiani E, Marrone L, Padovese V, Pajno C, Gebre Ab B
National Institute for Migration, Health and Poverty (NIHMP), Rome (Italy) Tigray Health Bureau LEPROSY IN NORTHERN ETHIOPIA
Objective. Leprosy is still a great health problem in some developing countries. 84% of new
cases and 74% of all registered cases of leprosy worldwide are observed in 9 countries. Since
2001, after the introduction of MDT, there was a reduction of new cases in Asia but not in Africa
and Latin America. In Africa, on the base of prevalence, there are more than 15 countries
where leprosy is still a public health problem. More than this, in countries as Somaly, Sierra
Leone etc, the problematic situation makes data non reliable. In Ethiopia, where there are 4-
5,000 new cases every year, there were no data until 2004. It is hard to pinpoint why it is tak-
ing so long to eradicate this illness: some causes might be the related stigma, the institution
of leprosaria in the past, poverty and living conditions, its chronic course. Implementing case
detection, treatment, advice and surveillance to the population is a possible solution.
Methods. We analyzed the cases of leprosy observed at the Italian Dermatological Center
(IDC) in Mekele, Tigray, in the Northern part of Ethiopia, between January 2005 and September
Results. During the first 5 years of activity we registered 366 patients with leprosy or deformity
related to leprosy, correspondent to the 0,7% of the total number of visits. M:F ratio was 2,5:1,
average age: 41,2 years, paediatric cases: 13 (3,6%).
Unlike other African countries, a relatively high proportion of MB cases was found.
We observed one case of coinfection with pulmonary TB and one with HIV, presenting with IRIS
as Type 1 Leproreaction.
Conclusions. Leprosy is a topical, still common disease in Northern Ethiopia. In most cases,
it can be easily suspected and treated.
Detecting new cases and monitoring disability caused by leprosy will be a challenge. One so-
lution is to implement long term surveillance in selected countries and make treatment available
for all.
1 Velema JP, Ebenso B, Fuzikawa PL. Evidence for the effectiveness of rehabilitation-in-the-community programmes.
Lepr Rev. 2008 Mar;79(1):65-82. Review. 2 Aseffa A, Engers H, Leekassa R. Editorial: leprosy research and current priorities in Ethiopia. Ethiop Med J. 2007Oct;45 Suppl 1:2p preceding 1.
3 Kawuma HJ. Potential role of dermatologists and dermatological services in developing and sustaining the leprosycontrol referral system in resource constrained settings. Lepr Rev. 2007 Mar;78(1):34-7. Review.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 40 Increasing People Opportunities (IPO) – Perugia (Italy) AFFORDABLE TREATMENT FOR COMMON DERMATOLOGIC

Skin diseases are very common in rural and urban areas of Ethiopia where essential drugs are often inaccessible to most of the population and traditional preparations by plant origin could often represent the only alternative to synthetic drugs. Improving knowledge of traditionalmedicines, assessing their safety and effectiveness in order to integrate traditional and modernstrategies of treatment, to ensure people access to health care, is a strong necessity. Devisingcosmeceutical formulation based on medicinal plants extracts, with a solid scientific rationale,could represent an interesting opportunity to produce cheap therapeutic solution for commondermatological diseases. We conducted a research in order to evaluate the safety and the efficacy of two herbal remedies, specifically two cosmeceutical preparation, a Thyme essential oil antifungal creamand a 10% Chamomile hydro-alcoholic extract cream. Our purpose was also to assess thelevel of the acceptance of these preparation by the local community and the possibility tolocally produce such preparations with a high standard of quality, for the benefit of the localcommunity in terms of health. We observed a significant high rate of response to the Thymeessential oil antifungal cream versus the placebo cream in the treated subjects that came backto the final visit.
There was an interesting rate of improvement with the Chamomile hydro-alcoholic extract cream, a large number of subjects healed or improved, but we didn't find any significant sta-tistic differences between treatment and placebo cream. In the light of our experience we can state that accomplishing RCT in a rural area of a de- veloping country is a very difficult task, considering the logistic, economic, socio-demographicand communicative problems. We can also affirm that a cream with 3% Thyme essential oilseems to be a cheap and easily available opportunity to treat and heal, mild to moderate casesof fungal infection, and that a common emollient cream could be a very effective interventionwhen treating mild to moderate cases of pityriasis alba and eczema-like lesions. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 41 Leiden University, Leiden, Netherland TREATMENT OF LEPROSY REACTIONS
Leprosy is a feared diseases because of the nerve damage that mostly occurs during the so- called reactions. When detected timely and treated properly most of this damage can be prevented and if already present some can be reversed.
Two types of nerve damaging reactions are known: the type I leprosy reaction or Reversal or downgrading reaction which is CMI mediated, and the Type II leprosy reaction or ErythemaNodosum Leprosum (ENL) which is a complex immune reaction in which the complement sys-tem is involved.
Reactions occur before during and after antimycobacterial treatment. In fact they belong to the normal course of the disease and have a certain duration, Type I: 3- 24 month, Type II:usually less than one month, but may become chronic.
The paper will discuss symptoms, immunological background and treatment Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 42 Leiden University, Leiden, Netherland HIV, AIDS, IRIS, 28 YEARS OF "EXPERIENCE"
The acquired immune deficiency syndrome was first seen in the early 1980th. The speaker has diagnosed and witnessed the first patients in the Netherlands and later in Zimbabwe. He has seen the problems in the Netherlands and Tanzania before HAART became available. He observed the IRIS when ARV's became instigated.
In this paper he will discuss the mistakes made in the past, show diagnostic signs and dis- cuss the IRIS.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 43 University Medical Centre Ljubljana (Slovenia) SEXUALLY TRANSMITTED INFECTIONS (STIs)

Sexually transmitted infections (STIs), have been recognised as a major public-health problem for a number of years worldwide. Their substantial morbidity, associated mortality, and disproportionate burden upon women, marginalised communities, and those with high risksexual lifestyles continue to drive their prioritisation. Nearly one million people acquire STI, including HIV, every day. The results of infection include acute symptoms, chronic infection, and serious delayed consequences such as infertility,ectopic pregnancy, cervical cancer, and the untimely deaths of infants and adults. The presencein a person of STIs such as syphilis, chancroid ulcers or genital herpes simplex virus infectiongreatly increases the risk of acquiring or transmitting HIV. The past quarter century has shownan extraordinary improvement in the quality of science and the number of services concerningSTIs and HIV all over the world. Furthermore, the increase of information and knowledge aboutthe impact of STIs/HIV on reproductive health has heightened the public recognition of STIs.
The major impact of STIs on public health today is caused by viral rather than bacterialinfections. Just one explanation is that while bacterial STIs can be cured with antibiotics, mostviral STIs still represent a major therapeutic challenge. New research suggests an especiallypotent interaction between very early HIV infection and other STIs. This interaction couldaccount for 40% or more of HIV transmissions. Given social, demographic and migratory trends,the population at risk for sexually transmitted infections will continue to grow dramatically. Theburden is greatest in the developing world, but industrialized nations can also be expected toexperience an increased burden of disease because of the prevalence of non-curable viralinfections, trends in sexual behaviour and increased travel.i Despite the substantial heterogeneity in diagnosis, treatment and surveillance systems, available data indicate, that STIs are again in the rise. Gains in STIs control may be achievedthrough harmonisation of laboratory diagnostic methods, clinical management, and sharinginnovation in STIs prevention.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 44 Lucia Romani
St.Vincent's Hospital, Sidney (Australia) ASSESSMENT OF SCABIES IN FIJI. A STUDY OF 13,000 PEOPLE
Background. Scabies and skin sores are recognised public health problems in Fiji and other
countries in the Pacific region. The World Health Organization estimates that 300 million people
worldwide are affected with scabies each year.
Scabies and skin sores can cause significant morbidity and lead to potential mortality. Scabies
can cause significant reduction in quality of life and consumes considerable time of health
care workers. Secondary infection of scabies can lead to cellulitis and septicaemia or lead to
glomerulonephritis and rheumatic fever. The Pacific region has among the highest rates of both
these diseases.
Methodology/Results. In 2007 we conducted an epidemiological cross-sectional study to
assess the prevalence of scabies and skin sores in Fiji.
The study enrolled 13,294 participants across all age groups and ethnicities. A total of 96 sites,including villages, settlements and schools were selected. Participants were asked to completequestionnaires regarding their skin conditions and medical history and had their skin checkedby a trained Fijian nurse, after patient consent was obtained. The results of the survey showeda scabies prevalence of 23% (3,092) of the population sampled, with 55% of the childrenaged 4-7 being infected, and 33% of the 0-3 year olds, but no age group was free of scabies.
The prevalence of infected sores in the participants with scabies was 21% (641).
Conclusions. These results suggest that scabies and skin sores are epidemic diseases in Fiji.
A comprehensive and well-coordinated scabies elimination and skin health program is urgently
needed. A pilot study to assess the efficacy of a mass treatment program is planned, comparing
ivermectin with permethrin assessing both cutaneous and non-cutaneous parameters. We aim
to find the most appropriate and cost-effective solution to justify the investment of time, man-
power and money to reduce the prevalence of scabies.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 45 Terence Ryan
International Foundation of Dermatology, London (UK) ISD TASK FORCE FOR COMMUNITY DERMATOLOGY
TO ISD October 23rd 2009Report Terence Ryan from the EADV BERLIN OCTOBER 9, 2009(Breaking Down Barriers the 2009 vision statement of this year's Congress.)With additional notes from a meeting of the Wound Healing and Lymphoedema interests at WHOGeneva the following week. Terence Ryan is a member and author for that group At a meeting of the Task force at which presentations were made by Terence Ryan, Shyam Vermaand Aldo Morrone discussions followed.
Other members present Vangee Handog, Luitgard Wiest. It was agreed there should be only oneorganisation and the CDI based in Rome may not be developed if the Task Force of the ISD worksout. (In other words, the Task Force would prefer to function under the auspices of ISD and notcreate another organization for Community Dermatology. The Task Force, however, would requireadministrative and financial support.) It was unanimously agreed that the Vision will be SKIN CARE FOR ALL.
The Mission is as follows:
• Community dermatology concerns populations rather than individuals. It requires data on preva-
lence and manpower. It trains community based workers to manage common problems of the skin.
Its interventions are low cost and address primarily but not exclusively*, the needs of those with
few resources. These may be isolated communities, mobile communities, or those affected by strife
or climate change.
• Rod Hay has pointed out to me the UV awareness programmes are for the Wealthy in the Com-
munity was well as for the albino
The Principle Aim is:
To seek Alliances with Common Goals to speak with One Voice.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 46 To lay the ground for funding skin care for populations worldwide which should be locally avail- able and sustainable. It is aimed at convincing funding agencies (The Global Fund,World Bank,European Union, Melissa and Bill Gates Foundation, Nippon Foundation to which Dermatology has unsuccessfullyapplied in the past) currently investing more than $22 billion per annum on Health Care. Thereis none for Skin Care perhaps due to multiple voices. Reference LANCET Editorial 2009 373 2083and the reviews to which it refers in that edition.
There are three major WHO linked Alliances who will collaborate.
1) The International League of Dermatological Societies(The only body formally approved
as having Official Relations). I see Community Dermatology being largely led through the ISDas the member with a long track record and active programme for the Developing World. Unlikethe ILDS the ISD acts through individuals and is now showing leadership through its Task Forcefor Community Dermatology. There are two other organizations which need to add to the onevoice.
Under the aegis of the ILDS the International Foundation for Dermatology(IFD) acting throughorganizations rather than individual members, focuses on skin diseases,. The International SkinCare Nursing Group affiliated to the World Council of Nurses is working with the IFD. I do notsee the Task force/ISD actually doing all the jobs, Aldo Morrone and the Instiute San Gallicanocan clearly be a member of our Executive but will do the job of managing mobile populationswithout the rest of us having to do that job other than assisting him.
All of the STI HIV/AIDS have alliances which need to be collaborators as skin orientated partners(The proposed link is through The International Union of Sexually Transmitted Infections. I havebeen given the Asian Chair as a name to contact.) 2) World Alliance for Wounds and Lymphoedema Care(WAWLC) pronounced walk.; a
new Alliance which expects to collaborate with the Task Force for Community Dermatology.
Wounds, burns, ulcers and swellings are being addressed by this newly formed (at WHO inthe Buruli Ulcer Devision,) Global Alliance for wounds and Lymphoedema (newly termed inGeneva the week after the October EADV congress). It has communication with the SurgicalDevision of WHO.
3) Neglected diseases (mostly Tropical) such asLeprosy, Lymphatic Filariasis,, Leishmaniasis,
Onchocerciasis, Buruli Ulcer.(following last week's meeting there is a move to increase the lia-son between leprosy and all three groups since Eric Prost from KIT the Nederlands Health Ad-visory group will chair WAWLC's programme development. He is working to bring ILEP (lep- Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 47 rosy's equivalent of the ILDS) closer to Dermatology. There are several well established linkssuch as the IFD and ISCNG with the Global Alliance for the Elimination of Lymphatic filariasis.
There are several initiatives for collaboration to gain a hearing with one voice. It receives hugesums of money for vector control but very little for morbidity control, Terence Ryan is a con-sultant to LEPRA and an advisor on morbidity control to Lymphatic Filariasis.
To identify and manage common skin problems in need of care, skin diseases, wounds, burns, ul-
cers, infections, tumours and swellings. None should be neglected.
1) To do a Health Needs Assessessment world-wide, collaborating with all organisations which
have common interests. This would collate data on need,human resources, essential drugs,education materials. The IFD has started on this. But members of the ISD can point toprevious studies and organize further studies by keeping in touch with the IFD programme.
2) To identify and make known our capacity and achievements at all levels of health care. Some
of these achievements have already been in precursor documents and include organisationssuch as The International Society of Dermatology,the International Foundation for Dermatology,and the International Skin Care Nursing Group, the International Union of Sexually TransmittedInfections, The World Alliance for Wounds and Lymphoedema Care (WAWLC) as well as theNeglected Disease programmes. Programmes to provide and conserve safe water forwashing(IFD.ISCNG and Procter and Gamble) or to eliminate Scabies(WHO/IFD /MercK) areother examples.
3) White papers. Each of the Neglected Diseases has explanatory documents on the book-
shelves of the WHO. WAWLC has one ready for publication which has gone through WHO'sEditing process. The ISD Task Force aims to have a publication after its meeting in Baroda nextyear.
Last week in Geneva WAWLC set out to have a short term funding committee chaired by Hen- rich Neilsen of The European Wound Management Association to finance the immediate objectivesof the publication of a WAWLK White Paper (already edited at WHO) and the preparation of Guide-lines for wound healing and Lymphoedema. The newly formed International LymphoedemaFramework under Christine Moffat will lead Monitoring and Evaluation for WAWLC. The CountryNeeds for Wound Healing will be led by Ramon Maldonado's Nephew Jose Conteras-Ruiz a Der-matologist leading Mexico's Wound Healing Organisation. I have invited him to prepare achapter for our Task Force on how wound healing and lymphoedema is part of our programme.

Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 48 The long term objective is to raise many Mil- Wherever Dermatology is placed it has to inform above lions of Dollars by applying in collaboration and below. It is at the centre of the pyramid for Education, Manpower, Service Funding Agencies.
with others-Speaking with One Voice. As weneed French Speaking Dermatologists I amconsidering asking Dr Anne Dompmartin United Nations Agencies / World Health
from Caen to assist him as she was an activespokesman at the WHO meeting on Wound National MOH (AAD, BAD, IADVL advisory committees)
healing. It was agreed in Geneva that an ap- Regional, State, Province, have Tertiary Hospitals,
peal based on needs must be fully supported where Senior Teams include
by evidence of capacity to achieve. WHO Dermatology Advisory Committees
also asked us to collate known evidence and District including Dermatology Advisors
not to spend time and money on reinventing Community Individual Dermatologists
the wheel. Also accepted and used was thefollowing diagram.
Each of the Three groups should have a White paper to back a one voice appeal for funds. Each group will fund its own document inde-
pendently. The document of the Task force will look to the ISD to fund the meeting in Baroda for
the preparation of its document. The WAWLC meeting that prepared their White paper was strongly
supported by Handicap International and paid for my attendance.
4) To foster altruism, community spirit, and participation. These fit uncomfortably with financially
managed care but occupy high moral ground. A society which neglects the needy is self de-structive.
To create all manner of carrots versus sticks.For Example WAWLC will identify "National He-roes" to reward.
Substitute thanks for where remuneration is deficient at all levels of health care. (ExamplesTJR introduced the Award System to the ILDS and in the UK converted a Dermatology Awardgiven once five yearly to one given annually.) The ISD's public thanks in 1999 to Smith KlineFrench led to their support of the creation of the International Skin Care Nursing Group.) ItsFellowships and Scholarships linked to FIDE are clearly needed.
Participation includes self awareness, advocacy of others, frame work building.
5) To express NEED in terms of the WHO Classification of Function.
Further explore Quality of Life and express skin failure of functionVizFailure of Communication, Barrier, Thermoregulation, and Sensation (numbness, itch andpain) To ask Andrew Findlay To take a lead on this.
6) To identify a work force at all levels of health service including other systems of health care
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 49 (viz: Indian or Chinese) used by at least 80% of populations.
Ensure that those best qualified in any system are placed in leadership positions.
7) To identify and Manage Inhibitions to Progress.
• Poverty• Strife• Climate change• Mobile populations• Bureaucracy• Litigation• Lack of advocacy for skin care Aldo Morrone has so far produced the most insight into these and his Organisation in Rome and Ethiopia is a leading example of Community Dermatology with which we have formed the
strongest alliance. Climate Change has a focus in the programme of the ISD.
8) To plan for increasing urbanization and recognize the needs of both rural and peri-urban pop-
9) To create an ISD website with which all interested persons can communicate (Bulletin
Board) and provide data collection on volunteer opportunities.
10) To collect data on skin care economics and the cost of not doing all of the above, (see pub-
lications by Rod Hay) This like much other data from House to House surveys would be chan-neled through existing projects such as that of the IFD.
11) All three groups are preparing Teaching Materials.Algorithms have been prepared for Der-
matology Antoine Mahe, Roberto Estrada, Aldo Morrone and several others. The IFD Com-munity Dermatology Journal is preparing one page Teaching Aids with Teaching Aids at LowCost. WAWLC has many plans.for teaching aids,including an extension of a Mobile phone pro-gramme salready piloted.
12) The ISD with its International Journal for Dermatology clearly has a role to play in supporting
ways of teaching in the Developing world.
Several of you want the task force to do concrete projects,take specific actions and find all the above insufficiently solid.
I believe raising 10million dollars could be the solid aim. However incorporated in the above are collecting data, teaching aids, publications, incentives, websites with bulletinboards and much else. as chairman that is what i want the task force to do. If there are otherprojects needed surely individuals and members of the alliance can do them and add to theachievements the task force wishes to collate but not necessarily solely own.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 50 Aisha Sethi
Section of Dermatology, University of Chicago, Chicago (USA) IMPORTED SKIN DISEASES
Once exotic skin diseases are not so exotic anymore as the importance of tropical diseases has increased in the face of environmental change, war, urbanisation, refugee problems, tourism, and the emergence of new diseases. It is especially important for dermatology resi-dents and practicing dermatologists to train in this arena as these diseases are crossing bordersand will be encountered with increased frequency in urban settings especially in the West. Thissession will cover some of the imported dermatoses that dermatologists in academic and pri-vate practice should be on the look out for given the increased ease of travel and globalization. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 51 Kassahun Desalegn Bilcha1, Adane Ayele1, Dagnachew Shibeshi1,
Christopher Lovell2

1 Department of Dermatovenereology, Faculty of Medicine, Addis Ababa University, Addis Ababa (Ethiopia); 2Deparment of Dermatology, Royal United Hospital, Bath (UK) PATCH TESTING AND CONTACT ALLERGENS IN ETHIOPIA RESULTS

Background. Patch testing is an important definite tool to diagnose allergic contact dermatitis
(ACD). While many countries use common allergens responsible to cause ACD in the population
for patch testing called standard series, some countries like Ethiopia have not yet developed
the standard series. Our objective is identification of common contact allergens for future stan-
dardization in Ethiopia.
Methodology. We patch tested 514 subjects with dermatitis according to the recommended
procedure using the European Baseline Series for one year.
Results. 52.7% of the tested subjects showed positive reaction for at least one allergen
tested. The top five contact allergens identified were nickel sulfate, fragrance mix, cobalt chlo-
ride, 4-tert-butylphenol formaldehyde resin, and potassium dichromate. Positive associations
have been detected between nickel allergy and female sex, butylphenol formaldehyde allergy
and female sex, butylphenol formaldehyde allergy and foot eczema, cement work and patch
test positivity, potassium dichromate allergy and cement work as well as potassium dichromate
allergy and hand dermatitis.
Conclusion. C omparable patch test results with other countries have been detected and the
European Baseline Series can be used as a standard series in Ethiopia with slight modification.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 52 Department of Dermatovenereology, Faculty of Medicine, University of Addis Ababa, Addis Ababa (Ethiopia) RESPONSE OF DIFFUSE CUTANEOUS LEISHMANIASIS (DCL)

Cutaneous leishmaniasis(CL) is endemic in over 80 countries including the Americas the Middle East, India, and East Africa(where Ethiopia belongs geographically). (Harrison's In our hospital CL including diffuse cutaneous leishmaniasis(DCL) is a common skin prob- lem(clinical observation 7 to 8 pts in two yrs) and treatment is usually discouraging with an-timonials and other systemic anti – leishminials showing either no response from the outsetor relapsing after treatment is discontinued, as is the case else where in the world.
Amphotericin B (liposomal) is a drug which can be used for treatment of leishminiasis (be it visceral or cutaneous) and it is a relatively newer drug option in our set up currently beingused for visceral leishminiasis. But apparently there is little or no experience of its use for DCLIn our country and even data from developed nations shows limited experience of liposomalampotericine B in diffuse cuaneous leishmaniasis. (up to date). So bearing this in mind we would like to report our first experience of the effect of ampho- tericin B in two of our patients with DCL using dosage recommended by FDA (food and drugadministration of U.S.A) for visceral leishminiasis.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 53 Health Science Center, University of Texas, Houston (USA) PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS
Although there is only one method to prevent transmission of sexually transmitted diseases (STIs), i.e. abstinence, there are many ways to reduce transmission. One of the most widely studied methods is the use of condoms. They have been proven to reduce, but not eliminate,transmission of human papillomavirues (HPV), herpes simplex viruses (HSV) and human immun-odeficiency virus (HIV). Circumcision is also an effective method to reduce transmission of these STIs, but not all studies have demonstrated the same degree of reduction. Daily use of such nucleoside ana-logues as valacyclovir by a person with genital herpes can reduce transmission of HSV to anuninfected partner. Antiretrovirals are commonly used by pregnant seropositive women to re-duce transmission of HIV to their infants. Similarly, antiretrovirals may reduce sexual transmis-sion to an uninfected partner. Effective therapy of other STIs may also help reduce transmission of HIV. Other methods under study include topical microbicides for intravaginal or intraanal use. Vaccines have beenvery useful to reduce non-sexual transmission of a number of viruses, but thus far vaccines areavailable for only a few STIs, i.e. hepatitis A and B as well as HPV types 6, 11, 16 and 18. It ishoped that the future will bring vaccines for other STIs, especially HIV, and they will be usedin combination with good public health measures, especially education.
Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 54 Institute of Dermatological Sciences, University of Milan, Milan (Italy) Tungiasis is an infestation caused by penetration in the skin of the gravid female of the flea Tunga penetrans Linnaeus 1758. Tunga penetrans currently lives in Central and South America, sub-Saharan Africa and Cen- tral Asia. Prevalence is very high in Brazil. The natural habitat of Tunga penetrans is representedby sandy and warm soil of deserts and beaches; furthermore, the flea lives in breedings, stablesand pigsties. Tungiasis is very common among dogs, cats and rats. Humans are accidentalhosts. Both the male and female are hematophagous. The life cycle of tunga lasts about fourweeks and consists of four stages: eggs, larva, pupa and adult. After copulation, the male dies.
Gravid female penetrates the skin. The mechanisms by which the flea penetrates are unknown:it was suggested that the flea releases keratolytic enzymes. In the skin, Tunga penetrans bur-rows a cavity with the head turned toward the upper dermis, in order to feed on the host'sblood, by means of a well-developed buccal apparatus. Only the end portion of the abdomenextrudes. Soon after penetration in the skin, the flea begins to produce eggs. The abdomen en-larges markedly ("physiogastry"): gravid female can reach a diameter of 1 cm (the male andthe non-gravid female are about 1 mm long). Ovaries can contain up to 200 eggs. Eggs andfeces are released outside through an opening in the epidermis, in proximity of the insect's analopening; this opening also allows the respiration. Eggs fall on the soil, where they hatch in 3-4 days, releasing larvae, whereupon gravid female dies. Ten to 15 days later, larvae develop intopupae, which, 1 to 2 weeks later, become adults.
Typical localizations of tungiasis are toes, peri- and sub-ungual folds, interdigital folds, sole and heel. These localizations can induce, because of pain, marked limitation in walking. Othersites are less commonly involved. Tungiasis is characterized clinically by a papular or nodular lesion, white or gray or yellowish in color, with a brown-black central opening, corresponding to the posterior portion of the ab-domen of the flea. Some cases with dozens, sometimes even hundreds, lesions were described.
Furthermore, less common clinical varieties were described: plantar wart-like lesions, as wellas crusted, bullous, pustular and ulcerative lesions. The penetration of tunga is asymptomatic: only when the insect increases in size, inflam- matory phenomena develop, leading to pain and/or pruritus. Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 55 Bacterial superinfections are the most frequent complications: Staphylococcus aureus is found in more than 35% of specimens, followed by enterococci (approximately 30%). Anaer-obic superinfections are not rare. Rare cases of lymphangitis, lymphadenitis, cellulitis, os-teomyelitis, gangrene, loss of nails, spontaneous amputation of the toes and sepsis werereported. Risk of tetanus should also be remembered. Diagnosis of tungiasis is based on the presence of papular or nodular lesions, either single or multiple, white or gray or yellowish in color, with a brown-black central opening, usually lo-calized to the feet, in a patient who recently visited an endemic area for tungiasis. Tungiasis should be differentiated from viral warts, foreign body granulomas, bacterial in- fections (furuncle, abscess, paronichia), nevi and tumors (melanoma). Treatment of choice consists in the complete surgical excision of the insect and peri-lesional tissues. The flea may also be removed by enlarging the orifice of the lesion by means of aneedle or the tip of a scalpel and exerting pressure at the sides. Residual cavity should thenundergo surgical debridement. Thereafter, it is necessary to apply a topical antibiotic. Systemicantibiotics are necessary when numerous and/or pustular lesions are present. Tetanus prophy-laxis is recommended. Fairly good results were also reported with electrodessication andcryotherapy. Prophylaxis consists in avoiding walking barefoot in endemic areas and the use of insec- Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 56 Institute of Dermatological Sciences, University of Milan, Milan (Italy) ERYSIPELAS: A RE-EMERGING DISEASE IN SOME WESTERN COUNTRIES
DEFINITION. Erysipelas (E.) is an acute bacterial disease of the dermis.
EPIDEMIOLOGY. In Italy, in the past, E. occurred especially in lower socio-economic class; now,
it is more frequent than in the past. E. is yet common in Eastern Europe, especially in Rumania.
Furthermore, its incidence is increasing in France. E. is more frequent in females with more than
65 years of age.
GENERAL PREDISPOSING FACTORS. The role of hot-humid climate must be confirmed, although,
in our personal experience, E. is more frequent in the summertime. Also the role of obesity must
be confirmed. Alcoholism is present in one third of patients. Insulin-dependent diabetes is present
in 15% of patients.
LOCAL PREDISPOSING FACTORS. These were studied almost exclusively for E. located on the
lower limbs. Chronic venous insufficiency is present in 45-50% of patients, tinea pedis or post-
traumatic ulcers of the skin in about one fourth of patients, a concomitant dermatitis in 15% and
lymphedema in 4%. In the last few years, sub-clinical tinea pedis has been considered the most
important local predisposing factor (the "front door") for E. on the lower limbs.
ETIOLOGY. E. is historically a streptococcal disease. Group A Streptococcus hemolyticus is involved
in 40-65% of cases, followed by Group G ( 25%), Group B (2-9%), Group C (5-7%) and Group
D (£ 1%). However, E. caused by Staphylococcus aureus is much more frequent than in the past:
now, in some Western countries, cases of E. caused by Staphylococcus spp., alone or associated
with Streptococcus spp., are 15-25% of all cases. Staphylococci are therefore emerging bacteria
in the etiology of E. According to the clinical point of view, no differences would exist between
E. caused by streptococci and E. due to staphylococci. However, it is possible that staphylococci
are more often responsible for bullous-hemorrhagic features. Other bacteria which can cause E.
are Haemophilus influenzae, which causes in children a characteristic monolateral, erythematous
edema in the peri-orbital area, accompanied by fever; Pseudomonas aeruginosa and Vibrio vulnificus.
The "trip" of bacteria which cause E. has been recently explained. Primary localizations of strep- tococci are pharynx and tonsils; from these localizations, they reach the oral cavity and finally theskin by hands. Primary localizations of staphylococci are the anterior nares; from this site they reachthe skin by hands. In conclusion, penetration in the skin of bacteria which cause E. may be exogenous Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 57 (for example tinea pedis) or by auto-inoculation (from pharynx, tonsils and anterior nares to theskin).
CLINICAL PICTURE. Early clinical picture is aspecific, although typical; it is characterized by asthenia,
chills and fever. The latter is always present, although of variable intensity and duration.
Skin manifestations are characterized by the sudden appearance of an erythematous-edematouslesion, bright red in color, often very large, with well-defined and regular borders, slowly enlargingtoward the periphery and accompanied by pain and fever. The consistency of the lesion is parenchy-matous-hard. Other manifestations include vesicles/blisters (30% of patients), almost exclusivelyon the limbs, petechiae/ecchymosis (<15% of patients), pustules and erosions/ulcers.
The legs and the thighs are involved in 85% of patients. E. occurs on the face (the so-called redface) in 15% of patients. In our experience, E. on the upper limbs is now more frequent thanin the past, when it was observed in 1% of patients. E. is sometimes accompanied by a deep lymphangitis. Also regional lymphnodes involvement isnot common. LABORATORY EXAMINATIONS. Common laboratory abnormalities are represented by
leukocytosis with neutrophilia, increased erythro-sedimentation rate, increased C-reactive protein
and increased -1 acid glycoprotein. Uncommon laboratory abnormalities include hyper- -globulinemia,
increased anti-streptolysinic titre (when streptococci are the etiological agents) or increased anti-
staphylolysinic titre (when staphylococci are involved). On the whole, laboratory abnormalities in
E. are aspecific.
Several tests have been suggested in order to obtain an etiological diagnosis; among them: directimmunofluorescence (positive in 65% of patients), latex agglutination (positive in 45-50% ofpatients), culture (positive in 25-30% of patients), increased anti-streptolysinic titre (positive in10-15% of patients) and hemoculture (positive in 5% of patients). Cultural examination of pathologicmaterial obtained by skin swab is possible only in those cases of E. characterized by vesicles, blisters,pustules or ulcers. In 20-30% of patients, etiological diagnosis is not possible. On the whole, the diagnosis of E. isbased on the clinical picture.
COMPLICATIONS. Systemic complications are rare and include acute glomerulonephritis (<1%
of patients), endocarditis (0.2%), sepsis (0.2%) and toxic-strep syndrome, for which no
epidemiological data are available.
Local complications are much more frequent. They include chronic lymphedema (25-35% of patients),abscess (6%), superficial or deep gangrene (4%), superficial or deep thrombophlebitis (>2%): thelatter is actually a predisposing factor rather than a complication of E. As far as the abscess is Impaginato OK:Layout 1 18-11-2009 19:09 Pagina 58 concerned, the latter seems to be more frequent in patients with insulin-dependent diabetes; moreover,abscess would be caused by penicillin-resistant staphylococcal strains. Chronic lymphedema (ele-phantiasis nostra streptogenes) is due to repeated recurrences of E. At the beginning,lymphedema is monolateral, but with time it becomes bilateral. The skin appears pachydermic,rough, xerotic, with very hard consistency. Frequent is the development of chronic ulcers. Necrotizing faciitis, considered in the past a complication of E., is now considered a true disease. Death is rare ( 0.5% of cases). Recurrences are very frequent (20-35% of patients).
DIAGNOSIS. The diagnosis of E. is usually easy. The most important clinical features for the diagnosis
are represented by skin manifestations (a single erythemato-edematous, large lesion, with well-
defined and regular borders, located on the face or the lower limbs) and fever. Laboratory examinations
are not helpful.
Differential diagnosis includes other infectious diseases (necrotizing fasciitis), inflammatory andallergic diseases (irritant/allergic contact dermatitis, toxic/allergic contact photodermatitis,Quincke edema, rosacea, thrombophlebitis) and immune-mediated diseases (systemic lupus ery-thematosus and dermatomyositis).
THERAPY. Systemic therapy. Antibiotics. I.m. or e.v. penicillin G for at least 10 days is the
treatment of choise. Other antibiotics that can be used are oral amoxicillin (2-3 g/day for at least
10 days) and oral amoxicillin/clavulanic acid (2-3 g/day for at least 10 days). In patients with a
clinical history of allergy to penicillins, oral clarithromycin can be used (1 g/day for at least 10 days).
Clarithromycin is effective in vitro and in vivo against both streptococci and staphylococci; furthermore,
no resistance has been observed so far. Non-steroidal anti-inflammatory drugs.
Non-steroidal anti-inflammatory drugs Theoretically, these drugs can be helpful in E. because
they reduce local edema and pain and allow the penetration of antibiotics in the place of infection.
However, some clinical studies suggested an association between the use of these drugs and the
development of necrotizing fasciitis. On the basis of these studies, these drugs should be avoided
in E. Heparins. Heparins.They are often employed both in the prevention and therapy of E. located
in the lower limbs, in order to prevent thromboembolic complications, in particular deep venous
thrombosis. However, a recent study demonstrated that the use of heparins is unnecessary both
in the prevention and in the therapy of E. of the lower limbs.
Topical therapy. It is usually unnecessary. Only in patients with vesicles, blisters, pustules, erosions
or ulcers antiseptic soaks may be helpful.
PROPHYLAXIS. As previously mentioned, recurrences occur in 20-35% of patients. Prophylaxis
is therefore necessary. The antibiotic of choice is i.m. penicillin benzatin every two weeks for a long
period of time


C2chi#080035 1.4

J_ID: CHI Customer A_ID: 08-0027 Cadmus Art: CHI20564 Date: 23-MAY-08 Stage: I CHIRALITY 00:000–000 (2008) Use of Large-Scale Chromatography in the Preparation of Armodafinil WILLY HAUCK,1 PHILIPPE ADAM,2 CHRISTELLE BOBIER,2* AND NELSON LANDMESSER3 1Novasep Inc., Boothwyn, Pennsylvania 2Novasep SAS, Pompey, France 3Cephalon Inc., West Chester, Pennsylvania Armodafinil, the (R)-enantiomer of modafinil, is a medication used to


Evolution of Drug-resistant Viral Populations during Interruption of Antiretroviral Therapy Running title: Evolution and fitness of drug-resistant viruses Dongning Wang1, Charles B. Hicks2, Neela Goswami2, Emi Tafoya3, Ruy M. Ribeiro3, Fangping Cai1, Alan S. Perelson3 and Feng Gao1* 1Duke Human Vaccine Institute and 2Department of Medicine, Duke University