Dr Muhammad Abrar

07/05/2026

2 years Old Child developed these Violaceous Vesiculo-bullous lesions from last 4 days after got bitten by a Sheep.

Diagnosis: orf

Orf (or contagious ecthyma) is a contagious zoonotic virus, specifically a parapoxvirus, that causes skin lesions (nodules or pustules) in sheep and goats, often known as "sore mouth".
It spreads to humans through direct contact, typically resulting in a single, painful, blood-tinged papule on the hands or arms that self-resolves within 3–6 weeks.

What Causes Orf (Disease)Viral Agent: The disease is caused by the orf virus, a member of the Parapoxvirus genus within the Poxviridae family.

Transmission: Humans contract the virus from infected sheep or goats, particularly lambs, or contaminated materials (fomites).Occupation: It is primarily an occupational disease affecting farmers, veterinarians, butchers, and shearers.

Animal Symptoms: In animals, it causes pustules on the lips, muzzle, and nostrils, making it difficult for them to eat.Orf Disease Symptoms in HumansOrf lesions usually appear 3–8 days after exposure.Initial Stage: A small, firm, red or reddish-blue lump (papule) appears.Progression: The lesion develops into a flat-topped, blood-tinged pustule or blister (target-like lesion).

Location: Usually occurs on fingers, hands, or forearms.Systemic Symptoms: Sometimes accompanied by mild fever, malaise, and swollen lymph nodes.Healing: The lesion generally heals without scarring, typically within 6 weeks, and rarely requires surgical intervention.

Treatment and Management

Self-Limiting: Orf is self-limiting and usually resolves without specific treatment.

Care: Keep the lesion clean and covered to reduce the risk of secondary infection.

Secondary Infection: Antibiotics may be necessary if a secondary bacterial infection occurs.

Vaccine (Animals): There is a live virus vaccine (e.g., Scabigard) used in the UK for sheep and lambs to reduce clinical signs, but it is not for human use.

07/05/2026

Male 45 years old presented with C/O multiple monomorphic hyper pigmented papules clustered over R cheek for 6 months, He has history of some procedure likely subcision and microneedling for acne scars from a local dermatologist likely he was treated with the instruments which weren't cleaned and disinfected properly.
Given the picture my diagnosis was HPV related flat/filliform warts.

07/05/2026

Plantar Fissures: An Advanced Diagnostic Framework for Dermatologists

Plantar fissuring is not a diagnosis.
It is a morphological endpoint of chronic barrier disruption, hyperkeratosis, or infection.

The clinical challenge is identifying the underlying driver.

---

🧠 Step 1: Pattern Before Diagnosis

Define:

- Symmetry (bilateral vs asymmetrical)
- Distribution (weight-bearing areas, web spaces, lateral foot)
- Dominant morphology:
- Hyperkeratosis
- Inflammation
- Vesicles / pustules
- Associated findings (nails, scalp, interdigital spaces)

---

⚖️ Core Differential Diagnoses

1. Palmoplantar Psoriasis

- Symmetrical, well-demarcated plaques
- Thick scale + deep fissures
- Mild itch
- Nail changes / extra-plantar involvement

---

2. Eczema Spectrum

Hyperkeratotic / Chronic Eczema

- Ill-defined borders
- Itch prominent
- Chronic fissuring

Contact Dermatitis (ACD / ICD)

- Exposure-related (footwear, chemicals)
- ACD: delayed, pruritic
- ICD: burning > itching

Dyshidrotic Eczema (Pompholyx)

- Recurrent, symmetrical
- Deep-seated vesicles (1–2 mm)
- Severe itch
- Resolves with scaling → fissures

---

3. Tinea Pedis (Moccasin Type)

- Often asymmetrical
- Diffuse scaling
- Interdigital maceration
- Associated onychomycosis

Pitfall: Steroids → tinea incognito

---

🚨 Expanded Differentials (Often Missed)

➤ Juvenile Plantar Dermatosis

- Children
- Forefoot, glazed erythema
- Web spaces spared

---

➤ Erythrasma

- Interdigital maceration
- Coral-red fluorescence (Wood’s lamp)

---

➤ Palmoplantar Pustulosis

- Sterile pustules + fissures

---

➤ Keratoderma

- Diffuse thickening
- Minimal inflammation

---

➤ Pitted Keratolysis

Key features:

- Superficial punched-out pits on pressure areas (heels, forefoot)
- Malodor
- Associated with hyperhidrosis
- Caused by bacterial infection (Corynebacteria)

Why it matters here:

- May coexist with fissuring due to maceration and barrier breakdown
- Easily missed if you focus only on “scale and cracks”
- Often misdiagnosed as fungal infection

---

➤ Mixed Pathology (Common Reality)

- Fungal + eczema overlap
- Secondary bacterial infection

---

🧪 Step 3: Investigations

- KOH scraping before steroids
- Fungal culture if needed
- Patch testing in chronic eczema
- Wood’s lamp (erythrasma)

---

🧠 Step 4: Clinical Decision Logic

- Symmetrical + sharp + thick scale → Psoriasis
- Itch + ill-defined + exposure → Eczema
- Asymmetrical + interdigital + scaling → Tinea
- Vesicular phase → Dyshidrotic eczema
- Malodor + pits → Pitted keratolysis

When in doubt → exclude fungus first

---

⚠️ Pitfalls

- Steroid response is misleading
- Many cases are overlap, not single pathology

---

26/04/2026

Piezogenic papules
are common, soft, skin-coloured papules found on the feet and wrists. They result from herniation of fat through the dermis. The name 'piezogenic' refers to the origin of the papules being pressure.
Piezogenic papules are mostly asymptomatic and are noticed incidentally. Occasionally they may be painful.
No treatment is required in the absence of symptoms.
For painful lesions, conservative management may include:
Restriction of weight-bearing exercise
Weight loss
Compression stockings
Foam rubber foot pads, or foam-fitting plastic heel cups

Intralesional corticosteroid injections have been documented to provide some relief for patients with piezogenic papules with underlying Ehlers-Danlos syndrome.
Surgical excision may be helpful if symptoms persist despite above managements but this is rarely necessary.

Muhammad Abrar.

09/04/2026

A 16 year old female wheelchair bound
Presented with
Diffuse hyperkeratotic, crusted plaques
Yellow-brown scaling over soles and knees
Fissuring + thickened stratum corneum
Likely subungual involvement

Previously treated for scabies with topical permethrin 5% but treatment was failed and was not adequate.

This is crusted scabies AKA Norwegian scabies
In crusted scabies:
•Massive mite proliferation (millions vs 10–15 in classical scabies)
•Due to:
•↓ cellular immunity
•Physical disability (wheelchair → ↓ scratching → mites proliferate)

Skin changes:
• Mites + eggs + f***s → hyperkeratosis + crust formation
• Leads to:
• Thick scales
• Minimal itching (paradoxically)
• Highly contagious

Why previous treatment failed?
•Topical permethrin cannot pe*****te thick keratin
•Inadequate keratolysis
•High mite burden → requires aggressive combination therapy.

CORRECT TREATMENT

1. Intensive Ivermectin Regimen (ESSENTIAL)

Ivermectin multiple-dose regimen:
• Ivermectin 200 µg/kg orally
• Schedule:
• Day 1, 2, 8, 9, 15
• Severe cases → add Day 22, 29

Topical Scabicide (more aggressive)
Permethrin 5% lotion:
• Apply daily for 7 days, then 2x/week until cure
• Apply:
• Whole body (including scalp, nails, soles)

Keratolytic Therapy (VERY IMPORTANT)

Without this → treatment failure
• Salicylic acid 5–10% ointment
OR
• Urea 20–40% cream

👉 Apply before permethrin to remove crusts

4. 🔹 Nail care (important)
• Cut nails short
• Apply permethrin under nails (brush)

• ALL household contacts:
• Treat simultaneously (even asymptomatic)
• Permethrin overnight × 1–2 applications

✔️ Environment
• Wash:
• Clothes, bedding → ≥60°C
• Non-washables:
• Seal in plastic bag × 72 hours (what i advise put non washables at place where sunlight is not reachable so eggs won’t survive)

✔️ Isolation (important here)
• Avoid close contact until treated
• Healthcare workers → gloves

✔️ Special note (wheelchair patient)
• Clean:
• Wheelchair cushions
• Armrests
• Frequently touched surfaces

Dr Muhammad Abrar.

01/04/2026

PPI (Risek,Nexum,etc) curse
I have seen numerous patients taking PPI on daily basis (many renowned consultants have been giving them ppi’s again and again and patients are taking these ppi’s for months and even in some cases for years)
I have previously made a detailed video on the
S/E of PPI if we take them for a long time
https://vt.tiktok.com/ZSH238pp2/
However today i wanted to discuss that how would we discontinue this PPI as stoping abruptly is not an option as pt will come with Rebound Acid Hypersecretion (RAHS) after stopping long-term PPI therapy.
After months–years of PPI use:
• Gastrin levels ↑ (hypergastrinemia)
• Parietal cells become hyperstimulated
‘’When PPI is stopped suddenly → acid rebounds above baseline
→ Patients develop:
• Severe heartburn
• Dyspepsia
• Acid regurgitation
• Sometimes mistaken as “disease recurrence”

🌼This typically occurs within 1–2 weeks of stopping🌼

How to safely stop PPIs
✅ 1. Step-down approach
If patient on Omeprazole 40 mg OD:
1. Reduce dose:• 40 → 20 mg OD (2–4 weeks)
2. Then: • 20 mg alternate day (2–4 weeks)
3. Then: Stop

✅ 2. Switch to H2 blocker (bridge therapy)
• After tapering PPI:• Start Famotidine 20–40 mg OD/BID
👉 Helps blunt rebound acid
✅ 3. On-demand PPI (instead of daily)
• Use only when symptoms occur
• Good for mild GERD patients
✅ 4. Add supportive meds during withdrawal
• Antacids (PRN)
• Alginates (e.g., Gaviscon) → very effective for reflux
• Sucralfate (short term mucosal protection)

⭕️When NOT to stop PPI (continue long-term)
Some patients actually need lifelong PPI:
• Severe erosive esophagitis (LA grade C/D)
• Barrett’s esophagus
• Chronic NSAID users (high risk)
• Zollinger-Ellison syndrome
• Recurrent peptic ulcer / GI bleed

*Dr Muhammad Abrar karamat*

261 likes, 24 comments. “معدے والے کیپسول کو زیادہ دیر تک استعمال کرنے کے نقصانات۔ Side effects of long term use of PPI (Risek)”

30/03/2026

A female have these lesions since birth
In winters these fissures bleeds as well
Decrease sensations on the palm as well

Since birth
• Worsens in winter
• Severe xerosis with fissuring + bleeding
• Symmetrical involvement of palms
• ↓ sensation

🔍 What I see on the image
• Diffuse hyperkeratosis of palms
• Marked xerosis with deep fissures (cracks)
• Accentuated palmar lines → almost “cracked mud” appearance
• No obvious erythematous active border (argues against tinea)
• Bilateral, symmetrical

⸻

🧠 Most Likely Diagnosis

✅ Hereditary Palmoplantar Keratoderma (PPK)

(specifically diffuse non-epidermolytic type likely)

⸻

⚠️ Important supporting points
• Congenital onset → strongly favors genetic keratoderma
• Winter exacerbation → xerosis-driven worsening
• Fissuring + bleeding → classic in PPK
• Reduced sensation → suggests:
• Either secondary thick keratin layer effect
• OR associated neuropathy variant (rare but important)

⸻

❗ Differentials (but less likely)
• Acquired PPK (no → because since birth)
• Chronic eczema (no → lifelong + no vesicles/oozing pattern)
• Tinea manuum (no → not unilateral, no active edge)
• Ichthyosis vulgaris (palms involved but this degree keratoderma less typical)

⸻

⚠️ Red Flag to Evaluate

Decreased sensation
→ Don’t ignore this

One should rule out:
• Peripheral neuropathy (esp. if diabetic later)
• Rare syndromic PPK (e.g., with nerve involvement)

👉 check:
• Light touch / vibration
• If needed → nerve conduction (only if clinically indicated)

⸻

💊 Management (Practical Dermatology Plan)

🔹 1. Keratolytics (Mainstay)
• Urea 20–40% (best starting)
• OR Salicylic acid 3–6%
• OR Ammonium lactate 12%

👉 Apply BD + after hand washing

⸻

🔹 2. Emollients (Very Important)
• Heavy occlusives:
• Petroleum jelly (Vaseline) at night
• Cotton gloves overnight → game changer

⸻

🔹 3. For fissures / bleeding
• Liquid paraffin + soft paraffin
• Short course:
• Topical antibiotic if infected cracks
• Superglue (cyanoacrylate) can be used for deep fissures (advanced tip)

⸻

🔹 4. If severe / refractory
• Consider:
• Topical retinoids
• Oral acitretin (low dose) → in severe PPK (specialist level)

⸻

🔹 5. Itching
• Mild topical steroid (NOT clobetasol long-term)
• e.g. mometasone short course

⸻

🚫 What NOT to do
• Avoid long-term clobetasol → will worsen thinning + fissures
• Avoid excessive soaps/detergents

⸻

📌 Simple Prescription Example
• Urea 25% cream → BD
• Vaseline → HS under gloves
• Mometasone → OD × 5–7 days (if inflamed/itchy)

⸻

💡 Final Clinical Insight

This is structural keratinization disorder, not just dryness—
so maintenance therapy is lifelong, not short course.
For hereditary PPK, oral acitretin can be very effective, but dosing in a female patient needs careful handling because of teratogenicity.

⸻

💊 Acitretin Dosage (PPK)

🔹 Starting dose (preferred)
• 0.2–0.3 mg/kg/day

👉 Practically:
• Most adults → 10–25 mg once daily with meals

🔹 Titration
• Increase gradually after 3–4 weeks if needed
• Usual effective range:
• 10–30 mg/day

🔹 Goal
• Use lowest effective dose
• Once improved → maintenance (e.g., 10 mg/day or alternate day)

⸻

⚠️ VERY IMPORTANT – Female Precautions

Acitretin is highly teratogenic

🚫 Absolute rules:
• NOT in pregnancy
• Avoid pregnancy during treatment AND for 3 YEARS after stopping

🔒 Contraception:
• At least 2 reliable methods
• Start 1 month before, continue during, and 3 years after

⸻

🧪 Baseline Investigations

Before starting:
• ✅ LFTs (ALT, AST)
• ✅ Lipid profile (TG, cholesterol)
• ✅ Pregnancy test (mandatory)
• ✅ RFTs (optional but good practice)

⸻

🔁 Monitoring
• LFTs + Lipids:
• At 1 month, then every 3 months
• Pregnancy test:
• Monthly (if of childbearing age)

⸻

⚠️ Common Side Effects

Mucocutaneous (very common)
• Dry lips (cheilitis)
• Dry skin
• Cracked palms worsen initially sometimes

👉 Always give:
• Lip balm
• Emollients

⸻

Metabolic
• ↑ Triglycerides
• ↑ LFTs

⸻

Others
• Hair thinning
• Photosensitivity

⸻

🚫 Avoid
• Alcohol (can prolong teratogenic metabolite formation → etretinate)
• Tetracyclines (↑ intracranial pressure risk)
• Vitamin A supplements

⸻

💡 Practical Tip (Very Important)

In PPK, high doses are NOT needed

👉 Low-dose long-term works best:
• e.g. 10 mg daily or even alternate day

⸻

📌 Sample Plan
• Tab Acitretin 10 mg OD after dinner
• Urea 25–40% topical BD
• Vaseline HS + gloves
• Review in 4 weeks with LFT + lipids

30/03/2026

Numerous tiny, monomorphic, skin-colored to whitish papules
• Follicular-based (each lesion centered around a follicle)
• Diffuse over trunk
• No erythema, vesicles, crusting, or excoriated papules
• Gives a “gooseflesh / sandpaper” texture

🧾 Lesion description
• Primary lesion: Papules
• Size: 1–2 mm
• Type: Follicular keratotic papules
• Color: Skin-colored to hypopigmented
• Surface: Rough, keratinous plug
• Distribution: Generalized (predominantly trunk)
• Arrangement: Discrete, monomorphic, folliculocentric

🧠 Most Likely Diagnosis

✅ Generalized Keratosis Pilaris (KP)

⸻

❗ Why KP fits best
• Follicular, uniform papules
• “Dry skin + rough feel” pattern
• No inflammatory signs
• Common in children
• Can be itchy (especially in winters/dry skin)

⸻

⚠️ Close Differentials (ruled out clinically)

❌ Lichen spinulosus
• More grouped plaques, spiny feel → not seen clearly here

❌ Phrynoderma (Vit A deficiency)
• Usually extensor limbs + malnutrition signs

❌ Miliaria rubra
• More erythematous, acute, sweating-related

❌ Folliculitis
• Would show pustules/inflammation

⸻

💊 Treatment (Practical Pediatric Plan)

🔹 1. Emollients (Cornerstone)
• Thick moisturizers:
• Liquid paraffin / white soft paraffin
• Apply 2–3 times daily

⸻

🔹 2. Keratolytics (mild for child)
• Urea 10–20% OR
• Ammonium lactate 12%

👉 Once daily at night initially

⸻

🔹 3. For itching
• Mild steroid:
• Hydrocortisone 1% short course (5–7 days)
• OR oral antihistamine if needed

⸻

🔹 4. Gentle skin care
• Avoid harsh soaps
• Lukewarm baths
• Pat dry, immediate moisturization

⸻

🚫 Avoid
• Strong keratolytics (high salicylic acid) in child
• Overuse of steroids

⸻

💡 Clinical Pearl

KP is:
• Chronic + benign
• Improves with age
• Relapses common in winter

⸻

📌 Simple Prescription
• Moisturizer → TDS
• Urea 10% lotion → HS
• Hydrocortisone 1% → OD × 5 days (if itchy)

Dr Muhammad Abrar

28/03/2026

10 years old boy have Multiple, symmetrical, follicular, keratotic, skin-colored papules over extensor surfaces feet and on back.
Type of lesions:
Multiple discrete to closely aggregated follicular papules
• Size:
Approximately 1–2 mm in diameter
• Color:
Skin-colored to slightly hypopigmented, with a shiny / glistening surface
• Surface:
Rough, keratotic, some appearing spiny/plugged (follicular keratin plugs)
• Shape:
Round to dome-shaped, uniform
• Margins:
Well-defined

⸻

📍 Distribution
• Predominantly over:
• Dorsum of foot
• Anterior aspect of legs (bilateral shins)
• History of spread to:
• Back

👉 Symmetrical distribution

⸻

🔗 Arrangement
• Follicular pattern
• Lesions are:
• Discrete but grouped
• In some areas → confluent giving a rough “gooseflesh” appearance

⸻

✋ Palpation (expected)
• Dry and rough texture
• Sandpaper-like feel
• Non-tender

⸻

⚠️ Associated features
• Mild xerosis
• Occasional pruritus (recent onset)
• No:
• Erythema
• Oozing
• Secondary infection
• Excoriations (significant)

⸻

❌ Negative findings (important for exam)
• No:
• Umbilication (rules out molluscum)
• Violaceous color (against lichen planus)
• Flat-topped shiny papules (against lichen nitidus)
• Vesicles or burrows (against scabies)

⸻

🧠 Provisional Diagnosis (exam style)

Keratosis pilaris
A disorder of follicular keratinization, characterized by keratotic follicular papules with symmetrical extensor distribution

⸻

🧾 One-line spot diagnosis (for viva)

“Multiple, symmetrical, follicular, keratotic, skin-colored papules over extensor surfaces consistent with keratosis pilaris.”

⸻

🔬 Differentials to mention (to score extra)
• Lichen nitidus
• Phrynoderma (vitamin A deficiency)
• Lichen spinulosus
• Early perforating dermatosis (less likely)

20/03/2026

Interesting case !

A 3 years old girl have multiple papules on exposed areas (hands, arms, feet)
Some lesions started as itchy papules/“boil like” —> then *Excoriate* —> *Crust* —> shallow ulcers (as shown in 1st image) some areas shows post inflammatory changes.

Seasonal (Summer only)
Recurrent *Every Year*
No family hx, co contact history , no burrows or nocturnal pruritus (_This excludes scabies_)

Diagnosis: Papular urticaria (insect bite hypersensitivity)
• Chronic but self-limiting with age
• Control = prevention + anti-inflammatory, not antibiotics alone.

Dr Muhammad Abrar

11/03/2026

I have seen many consultants (Orthopedic or Medical specialists any many other doctors) still prescribing Calcium+VitaminD3 combination even though we have clear evidence that
*Calcium + Vitamin D3 + Vitamin K2 + Magnesium is physiologically superior for bone healt*

Dr Muhammad Abrar