Granuloma annulare (GA) is a benign inflammatory disease associated with many conditions such as malignancy, trauma, thyroid disease, diabetes mellitus, and HIV infection. Common clinical subtypes include localized GA, generalized GA, subcutaneous GA, perforating GA, and patch GA. There exists an abundance of literature on GA, yet we know relatively little about its exact etiology and even less about its treatment. The paucity of conclusive data on effective treatment options is largely because the majority of published studies are limited to small case reports, case series, and retrospective studies. As such, there does not yet exist a gold standard of care to guide clinical management. Depending on the clinical subtype, the clinical prognosis for GA can vary. The localized variant generally self-resolves within 2 years without treatment, whereas the generalized form is more chronic and less responsive to treatment. This focused up-to-date review serves to summarize the latest therapeutic options available for GA.

Granuloma Annulare: A Focused Review of Therapeutic Options.

Rosacea is a common facial dermatosis but its definition and classification are still unclear, especially in terms of its links with demodicosis. Triggers of rosacea (ultraviolet light, heat, spicy foods, alcohol, stress, microbes) are currently considered to induce a cascading innate and then adaptive immune response that gets out of control. Recent histological and biochemical studies support the concept that this inflammatory response is a continuum, already present from the onset of the disease, even when no clinical signs of inflammation are visible. The Demodex mite is beginning to be accepted as one of the triggers of this inflammatory cascade, and its proliferation as a marker of rosacea; moreover, the papulopustules of rosacea can be effectively treated with topical acaricidal agents. Demodex proliferation appears to be a continuum process in rosacea, and may not be clinically visible at the onset of the disease. Molecular studies suggest that Demodex may induce tolerogenic dendritic cells and collaborate with vascular endothelial growth factor (VEGF) to induce T cell exhaustion and favor its own proliferation. These interactions among VEGF, Demodex, and immunity need to be explored further and the nosology of rosacea adapted accordingly. However, treating early rosacea, with only clinically visible vascular symptoms, with an acaricide may decrease early inflammation, limit potential flare-ups following laser treatment, and prevent the ultimate development of the papulopustules of rosacea. The effectiveness of this approach needs to be confirmed by prospective controlled clinical trials with long-term follow-up. Currently, the evidence suggests that patients with only vascular symptoms of rosacea should be carefully examined for the presence of follicular scales as signs of Demodex overgrowth or pityriasis folliculorum so that these patients, at least, can be treated early with an acaricidal cream.

/pdf/the-pathogenic-role-of-demodex-mites-in-rosacea-a-potential-184llgxfjz.pdf

The Pathogenic Role of Demodex Mites in Rosacea: A Potential Therapeutic Target Already in Erythematotelangiectatic Rosacea?

SUMMARY

The term ‘erythrokeratodermas’ or ‘erythrokeratodermias’ has been applied to a group of inherited disorders characterized by well-demarcated erythematous lesions and hyperkeratotic plaques. Connexin mutations have been demonstrated to be responsible for most cases of erythrokeratoderma variabilis but there remain some cases without demonstrated connexin mutations, suggesting genetic heterogeneity. The position of progressive symmetric erythrokeratoderma has become rather unclear. Loricin mutations have been found in some cases that clinically resemble variant Vohwinkel syndrome and other cases have features that overlap with those of erythrokeratoderma variablis. Whether progressive symmetric erythrokeratoderma exists as a distinct entity is under question.

Erythrokeratodermas: a classification in a state of flux?

Clinical evaluation of Lyme Borreliosis (LB) is the starting point for its diagnosis. The patient's medical history and clinical symptoms are fundamental for disease recognition. The heterogeneity in clinical manifestations of LB can be related to different causes, including the different strains of Borrelia, possible co-infection with other tick transmitted pathogens, and its interactions with the human host. This review aims at describing the heterogeneous symptoms of Lyme Borreliosis, as well as offering a practical approach for recognition of the disease, both in terms of clinical features and diagnostic/research tools.

/pdf/a-practical-approach-to-the-diagnosis-of-lyme-borreliosis-1n4o2haahj.pdf

A Practical Approach to the Diagnosis of Lyme Borreliosis: From Clinical Heterogeneity to Laboratory Methods.

Combinations of rifampin and clindamycin or rifampin, metronidazole, and moxifloxcin have been reported as effective treatments for hidradenitis suppurativa (HS) Hurley Stage 1 and Hurley Stage 2. Clinical trials suggest that for stage 1 and mild stage 2 HS, clindamycin 300 mg twice daily and rifampin 300 mg twice daily for 10 weeks can substantially abate HS in ~80% of cases and remit HS in ~50% of cases. Another study notes use of rifampin-moxifloxacin-metronidazole given for 6 weeks, dosed as rifampin (10 mg/kg once daily), moxifloxacin (400 mg daily), and metronidazole (500 mg thrice daily) with the metronidazole stopped at week 6. Rifampin and moxifloxacin were continued if the HS improved and side effects did not occur. Using this triple antibiotic regimen remission occurred in 100% Hurley Stage 1, 80% Hurly Stage 2, and 16.7 % of Hurley Stage 3 HS. The author typically gives HS clindamycin 300 mg and rifampin 300 mg, each twice daily, for 10 weeks and assesses if remission has occurred. If the patient has not achieved remission the author continues the regimen as long as the patient’s clinical status continues to improve without side effects. The reasons why rifampin is so effective against HS have not been fully defined and might involve rifampin's (1) antibacterial effects (2) effects on bacterial biofilms (3) anti-inflammatory effects (4) effects against granulomas (5) and immunomodulatory effects on neutrophils. It is notable that rifampin, although not first line, is an effective treatment for Clostridium difficile, a pathogen that arises during treatment with clindamycin. Thus, rifampin enhances safety when rifampin and clindamycin are combined for the treatment of HS.

/pdf/why-rifampin-rifampicin-is-a-key-component-in-the-antibiotic-21ch249whm.pdf

Why rifampin (rifampicin) is a key component in the antibiotic treatment of hidradenitis suppurativa: a review of rifampin's effects on bacteria, bacterial biofilms, and the human immune system

Background: Warts are mucocutaneous infections caused by human papillomavirus (HPV). Of the various modalities of treatment currently available, no single modality is uniformly efficacious and recurrences are common. Homologous autoimplantation is a minimally invasive procedure, which treats warts by stimulating a specific immune response against HPV. Aim: The aim of the study was to evaluate the clinical outcomes and recurrences after a single sitting of homologous autoimplantation therapy for multiple nonvenereal warts. Materials and Methods: Single homologous autoimplantation of wart tissue was done in 75 patients of multiple facial, palmoplantar, or common warts, reporting to a tertiary care dermatology center. They were assessed at 3 months for the outcome of the procedure, and those with complete clearance were followed up for 1 year for any recurrences. Results: Complete clearance was observed in 30 (40%) of the cases and 10 (13.3%) cases showed moderate clearance. In 13 (17.3%) cases, there was mild clearance, whereas 22 (29.3%) patients did not show any response to treatment. Patients with facial warts showed good therapeutic response with complete clearance seen in 62.5%, compared to plantar warts, where complete clearance was achieved only in 16%. At the end of the study period, recurrence was seen in only 1 (3.33%) patient in the complete clearance group. Conclusion: Autoimplantation therapy as a one time minimally invasive procedure has moderate efficacy in treating multiple warts with the best outcome being for facial warts. The virus-specific immunity generated in the process reduces the chances of recurrences.

Clinical outcomes and recurrences after homologous autoimplantation therapy for warts: A prospective study

Background: The localized form of granuloma annulare is usually self-limiting, resolving within 2 years. Generalized granuloma annulare, on the other hand, runs a protracted course, with spontaneous resolution being rare. It is also characterized by a later age of onset, an increased incidence of diabetes mellitus, poor response to therapy, and an increased prevalence of HLA Bw35. Objective: To assess the efficacy of monthly pulsed rifampicin, ofloxacin, and minocycline (ROM) therapy in the management of granuloma annulare. Methods : Six biopsy proven patients of granuloma annulare were included in the study, five of the generalized variety, and one localized. Three of these patients were resistant to standard modalities of treatment. All six patients were treated with pulses of once monthly ROM till complete resolution of all lesions. Results were analyzed in terms of complete resolution of lesions and side effects. Presence of comorbid conditions was noted. Result: All six patients were successfully treated with 4-8 pulses of monthly ROM. None of the patients reported any adverse effects. Limitations: Small sample size and the lack of a control group are limitations. Conclusion: Treatment with pulses of once monthly ROM caused complete resolution of lesions in both localized and generalized granuloma annulare, even in cases recalcitrant to conventional therapy. There were no side effects in any of the patients. Larger trials are needed to substantiate the efficacy of monthly ROM in granuloma annulare.

Monthly rifampicin, ofloxacin, and minocycline therapy for generalized and localized granuloma annulare.

Hansen's disease is a chronic infectious granulomatous disease with varied clinical presentation. Histoid Hansen's disease is an important emerging lepromatous subset of Hansen's disease known to mimic varied dermatoses. Occurrence of reactions, especially erythema nodosum leprosum (ENL), is rare in this form of leprosy. We report a case of Histoid Hansen's disease with initial presentation of ENL while undergoing management for infertility.

A dissimulate presentation of histoid Hansen's disease in the form of erythema nodosum leprosum.

Hansen's disease is caused by Mycobacterium leprae. The disease is known to involve the visceral organs including the testis apart from the skin and nerves in the lepromatous pole of leprosy due to widespread hematogenous dissemination of lepra bacilli. Furthermore, there can be testicular pain during the type 2 reaction in Hansen's disease. Filariasis is a disease caused by the parasitic nematode, Wuchereria bancrofti. This infection most commonly results in lymphedema and secondary vaginal hydrocele with an associated epididymo-orchitis. Acute epididymo-orchitis is either seen in the acute phase or as a part of secondary bacterial infections. The particular interest of this paper is to report the case of Hansen's disease who presented with testicular pain and posed a diagnostic dilemma when his pain did not respond to the standard mode of treatment and an alternate rare diagnosis was sought. This case report also emphasizes the need of reconsideration of diagnosis when the patient is not responding to standard therapy.

Acute scrotum: Hansen's disease versus filariasis.

Eponym has originated from the Greek word "eponymos" meaning "giving name". It is a tribute to the pioneers in the field who have significantly contributed towards present understanding of the subject. Syphilis has amazed and plagued mankind since eternity. This disease is a great masquerade and can humble best of physicians with its varied presentations. Keen and immaculate observations of these workers have eased our understanding of many signs and phenomenon associated with this disease. This has led to evolution of number of eponyms, perhaps no other disease has as many eponyms associated with it, as does syphilis. Eponyms such as Kassowitz's law, Clutton's joints, Higoumenaki sign, Argyll-Robertson pupil etc. help in providing easy milieu for remembering. Besides paying tributes to stalwarts in the field, who dedicated their lives for this cause, they also facilitated our current understanding of the great masquerade.

Sukriti Baveja

Papers

Clinical outcomes and recurrences after homologous autoimplantation therapy for warts: A prospective study

Monthly rifampicin, ofloxacin, and minocycline therapy for generalized and localized granuloma annulare.

A dissimulate presentation of histoid Hansen's disease in the form of erythema nodosum leprosum.

Acute scrotum: Hansen's disease versus filariasis.

Eponyms in syphilis.