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

13/02/2026

Male 45 years old presented with these lesions over face for 7 days have been applying dermovate on the lesion.

Morphology of lesion
Annular plaques
Raised, erythematous, slightly scaly border
Central clearing
Located over nose and malar area
History of topical clobetasol (Dermovate) use × 5 days.

This morphology is very suggestive of Dermatophytosis of the face (Tinea faciei) — but now likely modified by steroid use.

Differentials
1. Discoid lupus erythematosus (DLE) – but usually has adherent scaling, dyspigmentation, follicular plugging
2. Seborrheic dermatitis – more diffuse, greasy scaling
3. Granuloma annulare – non-scaly, firm border
4. Cutaneous leishmaniasis (consider in endemic areas of Pakistan) – usually ulcerative or infiltrative plaque
5. Rosacea – lacks annular raised border
Given central clearing + raised border → fungal is most consistent.

Suggested Confirmation (if needed)
•KOH mount from active border
•Scrap from peripheral edge, not center

Management :
Stop steroids

For localized lesion:
• Terbinafine 1% cream BD × 2–4 weeks
OR
• Luliconazole 1% OD × 2 weeks
OR
• Sertaconazole BD

Apply:
• 1–2 cm beyond margin
• Continue 1 week after clinical clearance

Terbinafine 250 mg OD × 2–4 weeks
• Or Itraconazole 100 mg BD × 2 weeks

(LFT baseline if prolonged therapy)

Counseling
• Avoid steroid combinations
• Do not share towels
• Check for tinea corporis / cruris / family infection

Final Impression:

*Most consistent with Tinea faciei → now evolving into Tinea incognito due to clobetasol use*

12/02/2026

B/L lip involvement
Erythema maceration crusting central lip oedema ē hemorrhage rusting
Most probably
Angular Cheilitis with Secondary Bacterial Infection
Likely mixed infection (Candida + Staph/Strep)

Why not herpatic stomatitis
No diffuse gingival involvement, no widespread oral ulcers lesion localized to commissures ,
HSV usually presents with small vesicle later on they rupture and made shallow ulcers

However if there is preceding fever, irritability painful ulcers
HSV would be reconsidered

Rx: mupiderm 2%, Miconazole, hydrocortisone 3-5 days only
Cephalaxin sus.

11/02/2026

Multiple tense bullae
• Clear to yellow fluid filled
• Surrounding erythema
• Acute onset (1 day)
• Localized to hand
• 2-month-old infant

Most Likely Diagnosis: Bullous Impetigo
Caused by Staphylococcus aureus (exfoliative toxin producing strains).
Why this fits:
• Sudden onset
• Flaccid/tense fluid-filled bullae
• Erythematous base
• Infant age group common
• No drug history (rules out SJS/TEN)
• Not present since birth (rules out EB)
• Localized, no grouped vesicles (less likely HSV)

Differential Diagnosis
1. Bullous impetigo
(most likely)
2. Bullous insect bite reaction
3. Neonatal HSV (if clustered vesicles, systemic signs)
4. Epidermolysis bullosa (would be recurrent/ trauma-induced since birth)
5. Staphylococcal scalded skin syndrome (would be generalized + systemic)

If Limited (tew lesions, no fever, no
systemic signs):
Local Care
• Clean gently with normal saline
• Do NOT intentionally rupture tense bullae
• If ruptured → remove loose roof gently and apply topical antibiotic
• Keep area dry
2
Topical Antibiotic (First Line)
• Mupirocin 2% ointment
• Apply 3 times daily
• For 5-7 days
OR
• Fusidic acid 2% (if mupirocin unavailable)

10/02/2026

A case shared by a fellow doctor for consultation.

10/02/2026

A female child
10 years old
Suffering from hairloss from last year
Hair loss is central thinning , widened part, ē preserved frontal hair line likely
FPHL.
Dermoscopy shows
Variation in hair shaft diameter
Increased vellus-like hairs
No scarring, no active inflammation

No family history of such illness
Previously she had dandruff which was relieved with Ketoconazole
Previously she seeks treatment improved but after discontinuing treatment again started having hair fall.
My
D/D’s
Chronic Telogen Effluvium
Diffuse Alopecia Areata
Trichotillomania
Traction alopecia
Loose anagen hair syndrome

05/08/2025

چھوٹے بچے مٹی چونا سیمنٹ وغیرہ کیوں کھاتے ہیں ؟
اُسکا علاج کیسے مُمکن ہے ؟
What is PICA?