Showing papers in "Indian Journal of Dermatology, Venereology and Leprology in 2008"

Clinical study of cutaneous drug eruptions in 200 patients.

Abstract: Two hundred patients (112 males and 88 females) with cutaneous drug eruption were studied. The aim was to recognize the offending drug, to evaluate mortality and morbidity, educate the patient and avoid self-administration and readministration of drugs. Fixed drug eruption was the commonest reaction, seen in 61 patients; other reactions being urticaria and angioedema, morbilliform rash in 37, pruritus in 25, Stevens Johnson Syndrome (SJS) in 6, purpura in 6, exfoliative dermatitis in 5, photosensitivity in 5, toxic epidermal necrolysis in 2, acneiform eruption in 3, erythema multiforme in 2. Maximum patients belonged to the age group 41-50, followed by 21-30 and 31-40 years. The youngest was 1 year old and the oldest was 80 years old. Period of development of lesion after intake of drug varied from 1 day to 45 days. Cotrimoxazole was the commonest drug, in 26 cases; followed by Ibuprofen in 20 cases.

Prevention of mother-to-child transmission

Abstract: This report describes the rate of mother-to-child transmission (MTCT) in developing countries with emphasis on India. It presents a three-pronged approach to the prevention of MTCT: 1) primary preventin of HIV among parents; 2) prevention of unwanted pregnancy in HIV-infected females; and 3) core interventins to prevent MTCT by HIV-positive mothers. Four scenarios are presented for consideration when discussing HIV during pregnancy in various clinical situations. (excerpt)

Many faces of cutaneous leishmaniasis.

Abstract: Background: Cutaneous leishmaniasis (CL) is known for its clinical diversity and increasing numbers of new and rare variants of the disease are being reported these days Aim: The aim of this descriptive study was to look for and report the atypical presentations of this common disease occurring in Pakistan Methods: The study was carried out in three hospitals (MH, Rawalpindi; PAF Hospital, Sargodha; and CMH, Muzaffarabad) from 2002 to 2006 Military and civilian patients of all ages, both males and females, belonging to central and north Punjab province and Kashmir were included in the study Clinical as well as parasitological features of cutaneous leishmaniasis were studied The unusual lesions were photographed and categorized accordingly using simple descriptive statistics Results: Out of 718 patients of cutaneous leishmaniasis, 41 (57%) had unusual presentations The commonest among unusual morphologies was lupoid leishmaniasis 14 (341%), followed by sporotrichoid 5 (121%), paronychial 3 (73%), lid leishmaniasis 2 (49%), psoriasiform 2 (49%), mycetoma-like 2 (49%), erysipeloid 2 (49%), chancriform 2 (49%), whitlow 1 (24%), scar leishmaniasis 1 (24%), DLE-like 1 (24%), 'squamous cell carcinoma'-like 1 (24%), zosteriform 1 (24%), eczematous 1 (24%), verrucous 1 (24%), palmar/plantar 1 (24%) and mucocutaneous 1 (24%) Conclusion: In Pakistan, an endemic country for CL, the possibility of CL should be kept in mind while diagnosing common dermatological diseases like erysipelas, chronic eczema, herpes zoster, paronychia; and uncommon disorders like lupus vulgaris, squamous cell carcinoma, sporotrichosis, mycetoma and other deep mycoses

Comparison of potassium hydroxide mount and mycological culture with histopathologic examination using periodic acid-Schiff staining of the nail clippings in the diagnosis of onychomycosis.

Abstract: Background: Onychomycosis is a common problem noticed in clinical practice. Currently available standard laboratory methods show inconsistent sensitivity; hence there is a need for newer methods of detection. Aims: This study involves comparison of standard laboratory tests in the diagnosis of onychomycosis, namely, potassium hydroxide mount (KOH mount) and mycological culture, with histopathologic examination using periodic acid-Schiff (PAS) staining of the nail clippings. Methods: A total of 101 patients with clinically suspected onychomycosis were selected. Nail scrapings and clippings were subjected to KOH mount for direct microscopic examination, culture using Sabouraud's dextrose agar (with and without antibiotics) and histopathologic examination with PAS staining (HP/PAS). Statistical analysis was done by McNemar's test. Results: Direct microscopy with KOH mount, mycological culture, and HP/PAS showed positive results in 54 (53%), 35 (35%), and 76 (75%) patients respectively. Laboratory evidence of fungal infection was obtained in 84 samples by at least one of these three methods. Using this as the denominator, HP/PAS had a sensitivity of 90%, which was significantly higher compared to that of KOH mount (64%) or mycological culture (42%). Conclusions: Histopathologic diagnosis with PAS staining of nail clippings was the most sensitive among the tests. It was easy to perform, rapid, and gave significantly higher rates of detection of onychomycosis compared to the standard methods, namely KOH mount and mycological culture.

Standard guidelines of care for chemical peels

Abstract: Chemical peeling is the application of a chemical agent to the skin, which causes controlled destruction of a part of or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues. Indications for chemical peeling include pigmentary disorders, superficial acne scars, ageing skin changes, and benign epidermal growths. Contraindications include patients with active bacterial, viral or fungal infection, tendency to keloid formation, facial dermatitis, taking photosensitizing medications and unrealistic expectations. Physicians' qualifications : The physician performing chemical peeling should have completed postgraduate training in dermatology. The training for chemical peeling may be acquired during post graduation or later at a center that provides education and training in cutaneous surgery or in focused workshops providing such training. The physician should have adequate knowledge of the different peeling agents used, the process of wound healing, the technique as well as the identification and management of complications. Facility : Chemical peeling can be performed safely in any clinic/outpatient day care dermatosurgical facility. Preoperative counseling and Informed consent : A detailed consent form listing details about the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure and should clearly mention if more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, presentations, and personal discussions. The need for postoperative medical therapy should be emphasized. Superficial peels are considered safe in Indian patients. Medium depth peels should be performed with great caution, especially in dark skinned patients. Deep peels are not recommended for Indian skin. It is essential to do prepeel priming of the patient's skin with sunscreens, hydroquinone and tretinoin for 2-4 weeks. Endpoints in peels: For glycolic acid peels: The peel is neutralized after a predetermined duration of time (usually three minutes). However, if erythema or epidermolysis occurs, seen as grayish white appearance of the epidermis or as small blisters, the peel must be immediately neutralized with 10-15% sodium bicarbonate solution, regardless of the duration of application of the peel. The end-point is frosting for TCA peels, which are neutralized either with a neutralizing agent or cold water, starting from the eyelids and then the entire face. For salicylic acid peels, the end point is the pseudofrost formed when the salicylic acid crystallizes. Generally, 1-3 coats are applied to get an even frost; it is then washed with water after 3-5 minutes, after the burning has subsided. Jessner's solution is applied in 1-3 coats until even frosting is achieved or erythema is seen. Postoperative care includes sunscreens and moisturizers Peels may be repeated weekly, fortnightly or monthly, depending on the type and depth of the peel.

Comparison of intralesional verapamil with intralesional triamcinolone in the treatment of hypertrophic scars and keloids.

Abstract: Background : The calcium channel blocker, verapamil stimulates procollagenase synthesis in keloids and hypertrophic scars. Aim : To study the effect of verapamil in the treatment of hypertrophic scars and keloids and to evaluate the effect of verapamil on the rate of reduction of hypertrophic scars and keloids in comparison with triamcinolone. Methods : The study was a randomized, single blind, parallel group study in which 54 patients were allocated to to receive either verapamil or triamcinolone. Drugs were administered intralesionally in both groups. Improvement of the scar was measured using modified Vancouver scale and by using a centimeter scale serially till the scar flattened. Results : There was a reduction in vascularity, pliability, height and width of the scar with both the drugs after 3 weeks of treatment. These changes were present at one year of follow-up after stopping treatment. Scar pigmentation was not changed desirably by either drug. Length of the scars was also not altered significantly by either drug. The rate of reduction in vascularity, pliability, height and width of the scar with triamcinolone was faster than with verapamil. Adverse drug reactions were more with triamcinolone than with verapamil. Conclusion : Intralesional verapamil may be a suitable alternative to triamcinolone in the treatment of hypertrophic scars and keloids.

Role of stressful life events in induction or exacerbation of psoriasis and chronic urticaria

Abstract: Background: The possibility of a causal influence of emotional stress, especially of stressful life events, on the course of various skin diseases has long been postulated. Previous reports addressing its influence on skin psoriasis and chronic urticaria have been mainly anecdotal. Objective: The aim of this study was to evaluate the stressful events of life within 1 year preceding onset or exacerbation of skin disease in patients of psoriasis vulgaris and chronic urticaria. Method: Fifty consecutive clinically diagnosed psoriasis patients and 50 consecutive clinically diagnosed chronic urticaria patients were examined clinically and administered Gurmeet Singh's presumptive stressful life events scale. Results: Stressful life events were seen in 26% of the patients in the psoriasis vulgaris group and 16% of the patients in the chronic urticaria group within 1 year preceding onset or exacerbation of skin disease. In the psoriasis vulgaris group, the most common stressful life event seen was financial loss or problems (8%), followed by death of close family member (4%), sexual problems (4%), family conflict (2%), major personal illness or injury (2%),and transfer or change in working conditions (2%), failure in examinations (2%), family member unemployed (2%), illness of family member (2%), getting married or engaged (2%), miscellaneous (2%). In the chronic urticaria group, the most common stressful life event seen was death of a close family member (6%), followed by family conflict (2%), financial loss or problems (2%), sexual problems (2%), illness of family member (2%), getting married or engaged (2%), trouble at work with colleagues, superiors, or subordinates (2%), going on a pleasure trip (2%) and extramarital relations (2%). Conclusion: Psychological stress plays a significant role in triggering or exacerbating dermatological diseases. Our study indicates the role of relaxation therapies and stress management programs in chronic diseases such as psoriasis and chronic urticaria. Psychological interventions can help individuals to reinterpret events and develop strategies to cope with stressful events, thus decreasing morbidity due to these diseases.

Adverse effects of antiretroviral treatment

Abstract: Background: The introduction of highly active antiretroviral therapy (HAART) has led to significant reduction in acquired immune deficiency syndrome (AIDS)-related morbidity and mortality. Adverse drug reactions (ADRs) to antiretroviral treatment (ART) are however, major obstacles in its success. Aims: We sought to study the adverse effects of ART in a resource-restricted setting in India. Methods: Hundred patients on ART were studied prospectively over a period of two years. All patients were asked to visit the clinic if they developed any symptoms or on a monthly basis. They were screened clinically and investigated suitably for any ADRs. Result: Out of the 100 patients, ten patients did not come for follow-up; only 90 cases were available for evaluation. ADRs were observed in 64 cases (71.1%) - the maximal frequency of ADRs was seen with zidovudine (AZT) (50%) followed by stavudine (d4T) (47.9%), efavirenz (EFV) (45.4%) and finally, Nevirapine (NVP) (18.4%). Most common ADRs were cutaneous (44.4%) followed by hematological (32.2%), neurological (31.1%), metabolic (22.2%) and gastrointestinal (20%). Most common cutaneous ADRs observed were nail hyperpigmentation (14.4%) and rash (13.3%). Immune reconstitution inflammatory syndrome (IRIS) was observed as a paradoxical reaction to ART in 20 (22.2%) cases. Conclusion: To optimize adherence and thus, efficacy of ART, clinicians must focus on preventing adverse effects whenever possible, and distinguish those that are self-limited from those that are potentially serious.

Standard guidelines of care for vitiligo surgery.

Abstract: Vitiligo surgery is an effective method of treatment for selected, resistant vitiligo patches in patients with vitiligo. Physician's qualifications: The physician performing vitiligo surgery should have completed postgraduate training in dermatology which included training in vitiligo surgery. If the center for postgraduation does not provide education and training in cutaneous surgery, the training may be obtained at the surgical table (hands-on) under the supervision of an appropriately trained and experienced dermatosurgeon at a center that routinely performs the procedure. Training may also be obtained in dedicated workshops. In addition to the surgical techniques, training should include local anesthesia and emergency resuscitation and care. Facility: Vitiligo surgery can be performed safely in an outpatient day care dermatosurgical facility. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place, with which all nursing staff should be familiar. Vitiligo grafting for extensive areas may need general anesthesia and full operation theater facility in a hospital setting and the presence of an anesthetist is recommended in such cases. Indications for vitiligo surgery : Surgery is indicated for stable vitiligo that does not respond to medical treatment. While there is no consensus on definitive parameters for stability, the Task Force suggests the absence of progression of disease for the past one year as a definition of stability. Test grafting may be performed in doubtful cases to detect stability. Preoperative counseling and Informed consent: A detailed consent form elaborating the procedure and possible complications should be signed by the patient. The patient should be informed of the nature of the disease and that the determination of stability is only a vague guide. The consent form should specifically state the limitations of the procedure, about the possible future progression of disease and whether more procedures will be needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures and one-to-one discussions. The need for concomitant medical therapy should be emphasized and the patient should understand that proper results take time (a few months to a year). Preoperative laboratory studies include hemogram including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time), and blood chemistry profile. Screening for antibodies for hepatitis B surface antigen and HIV is recommended depending on individual requirements. Anesthesia: Lignocaine (2%) with or without adrenaline is generally used for anesthesia; infiltration and nerve block anesthesia are adequate in most cases. General anesthesia may be needed in patients with extensive lesions. Postoperative care: Proper postoperative immobilization and care are very important to obtain satisfactory results.

Evening primrose oil is effective in atopic dermatitis: A randomized placebo-controlled trial

Abstract: Background: Atopic dermatitis (AD) is a chronic, relapsing, itchy dermatosis of multifactorial origin, which commonly starts in childhood. Defective metabolism of essential fatty acids leading to relative dominance of pro-inflammatory prostaglandins (PGE 2 and PGF 2 ) has been reported as an important factor in the pathogenesis of AD. Evening primrose oil (EPO) as a source of gamma-linolenic acid (GLA) has been of interest in the management of AD. Aim: To evaluate the efficacy and safety of EPO in atopic dermatitis in our patients. Methods: Consecutive new out-patient department (OPD) patients of a referral hospital in Kolkata clinically diagnosed as having AD were randomly allocated to two groups. To the first group, evening primrose oil was supplied as 500-mg oval clear unmarked capsules, while placebo capsules identical in appearance and containing 300 mg of sunflower oil were given to the other group. Treatment continued for a period of 5 months. With pre-designed scoring system (based on four major parameters: extent, intensity, itching, and dryness), clinical evaluation was done at baseline and subsequent monthly visits. Data of the first 25 patients from each group who completed the 5 months of trial were compiled and analyzed. Results: At the end of the fifth month, 24 (96%) patients of EPO group and 8 (32%) patients of placebo group showed improvement. There was significant difference in outcome of treatment between two groups (P < 0.00001). No significant adverse effect was reported by any patient/guardian at any point of assessment. Conclusion: Evening primrose oil is a safe and effective medicine in management of AD. However, since not all researchers across the world have found the same good result, further large trials on Indian patients are needed.

Life quality assessment among patients with vitiligo: comparison of married and single patients in Iran.

Abstract: Background and Aims: Vitiligo is known to affect the quality of social and personal life in some countries This study aims to assess the quality of life (QOL) in vitiligo sufferers among the Iranian population and to evaluate its relation with different variables Methods: One hundred vitiligo patients answered a questionnaire based on the Dermatology Life Quality Index (DLQI) Results: The mean DLQI score was 816 There were statistically significant relationships between DLQI scores and marital status, skin phototype, and disease extension independently Conclusions: This study shows that vitiligo has a major impact on the QOL of patients in Iran Hence dermatologists should pay attention to the psychological effects of this cosmetic disease and try to decrease its extension and disfiguring effects by various treatments

Arsenicosis: Diagnosis and treatment

Abstract: Diagnosis of arsenicosis relies on both clinical and laboratory criteria, but principally it can be diagnosed on the basis of its cutaneous manifestations. Cutaneous manifestations (melanosis, keratosis, and cutaneous cancers) are essential clues in the diagnosis, and trained dermatologists or arsenic experts are able to clinically confirm a case even without laboratory backup. Although systemic manifestations are not considered as diagnostic hallmarks, yet their presence serves as important telltale signs in arriving at the diagnosis. In countries where laboratory facilities are available, measuring the level of arsenic in drinking water (consumed in the last 6 months), urine, hair, and nails is of immense value. Newer biomarkers of arsenic exposure are being explored to provide early information about arsenic intoxication, of which urinary porphyrin level, blood metallothionein have shown promising results. Controlling the problem of arsenicosis depends on various factors, of which the most important is cessation of intake of arsenic-contaminated water. Deep wells, traditional dug wells, treatment of surface water, rainwater harvesting, and removing arsenic from the contaminated water by arsenic removal plant or arsenic treatment unit are the available options for providing arsenic-free drinking water. The role of nutrition and antioxidants in preventing the onset of symptoms of arsenicosis is also of importance. Nonspecific therapies (e.g., keratolytics for hyperkeratosis) cannot also be ignored and serve as palliative measures. The persons affected need to be followed up at regular intervals to detect the onset of cancers (if any) at the earliest. Role of counseling and education should never be underestimated since absence of public awareness can undermine all efforts of mitigation measures.

Stevens Johnson syndrome, toxic epidermal necrolysis and SJS-TEN overlap: a retrospective study of causative drugs and clinical outcome.

Abstract: Background and Aims: Stevens Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and SJS-TEN overlap are serious adverse cutaneous drug reactions. Drugs are often implicated in these reactions. Methods: A retrospective analysis of inpatients' data with these dermatological diagnoses were carried out for three years, to study the causative drugs, clinical outcome, and mortality in these conditions. Results: Thirty patients (15 TEN, nine SJS-TEN overlap, and six SJS) were admitted. In 21 cases, multiple drugs were implicated whereas single drugs were responsible in nine. Anticonvulsants (35.08%) were the most commonly implicated drugs followed by antibiotics (33.33%) and NSAIDS (24.56%). Twenty-five patients recovered whereas five died (four TEN, one SJS-TEN overlap). Conclusion: Anticonvulsants, antibiotics and NSAIDs were the most frequently implicated drugs. TEN causes higher mortality than both SJS and SJS-TEN overlap.

An open labeled, comparative clinical study on efficacy and tolerability of oral minipulse of steroid (OMP) alone, OMP with PUVA and broad / narrow band UVB phototherapy in progressive vitiligo.

Abstract: Background: Several modalities of treatment have been tried in vitiligo with varied results; however, Indian data on comparative studies of two or more therapies are limited. Aims: We compared different phototherapy methods with an oral steroid as an adjunct to determine the method with the best tolerability and efficacy. Methods: Eighty-six patients with progressive vitiligo were randomly assigned to different study groups according to a continuous selection method over a period of one year. Group 1 was given OMP + PUVA, group 2 OMP + UVB (NB), group 3 OMP + UVB (BB) and group 4 was given OMP alone. Each patient was followed up for six months and then released from treatment. Clinical evaluation was made at the end of three and six months. Results: In group 1 (OMP + PUVA), marked improvement was seen in 18.51% while moderate improvement was seen in 66.66% of the patients. Marked improvement was seen in 37.03% in group 2 (OMP + NB-UVB) while 44.44% had moderate improvement. In group 3 (OMP + BB UVB), 8.33% showed marked improvement while moderate improvement was seen in 25% of the patients. Marked and moderate improvement was seen in 5 and 10% of group 4 (OMP) patients, respectively. Conclusions: Our study compared four treatment modalities in vitiligo patients, out of which oral minipulse of steroids (OMP) only had an adjunct value and was not very effective by itself. Narrow band UVB has a definite edge over broad band UVB and should be preferred when both options are available. NB-UVB and PUVA showed comparable efficacy.

Autologous serum therapy in chronic urticaria: Old wine in a new bottle

Abstract: Background: Chronic urticaria (CU) is one of the most challenging and frustrating therapeutic problems faced by a dermatologist. A recent demonstration of abnormal type 1 reactions to intradermal autologous serum injections in some CU patients has led to the characterization of a new subgroup of autoimmune chronic urticaria. This has rekindled interest in the age-old practice of autologous blood injections as a theoretically sound treatment option in these patients. Aims: To evaluate the efficacy of repeated autologous serum injections (ASIs) in patients with recalcitrant chronic urticaria. Methods: A cohort of 62 (32 females) CU patients with a positive autologous serum skin test (ASST) (group 1) was prospectively analyzed for the efficacy of nine consecutive weekly autologous serum injections with a postintervention follow-up of 12 weeks. Another group of 13 (seven females) CU patients with negative ASST (group 2) was also treated similarly. In both groups, six separate parameters of disease severity and activity were recorded. Results: Demographic and disease variables were comparable in both groups. The mean duration of disease was 1.9 ± 0.3 years (range = 3 months to 32 years) in group 1 and 1.5 ± 0.2 years (range = 3 months to 10 years) in group 2. In the ASST (+) group, 35.5% patients were completely asymptomatic at the end of the follow-up while an additional 24.2% were markedly improved. In the ASST (−) group, these figures were 23 and 23% respectively. The intergroup difference for complete subsidence was statistically significant (P < 0.05). In both groups, the most marked reduction was seen in pruritus and antihistamine use scores followed by the size and frequency of the wheals. Conclusion: Autologous serum therapy is effective in a significant proportion of ASST (+) patients with CU. A smaller but still substantial number of ASST (−) patients also benefited from this treatment.

Pathogenesis, clinical features and pathology of chronic arsenicosis

Abstract: Arsenicosis is a multisystem disorder, with virtually no system spared from its vicious claw; though its predominant manifestations are linked to cutaneous involvement. Cutaneous effects take the form of pigmentary changes, hyperkeratosis, and skin cancers (Bowen's disease, squamous cell carcinoma, and basal cell epithelioma). Peripheral vascular disease (blackfoot disease), hypertension, ischemic heart disease, noncirrhotic portal hypertension, hepatomegaly, peripheral neuropathy, respiratory and renal involvement, bad obstetrical outcome, hematological disturbances, and diabetes mellitus are among the other clinical features linked to arsenic toxicity. The effects are mediated principally by the trivalent form of arsenic (arsenite), which by its ability to bind with sulfhydryl groups present in various essential compounds leads to inactivation and derangement of body function. Though the toxicities are mostly linked to the trivalent state, arsenic is consumed mainly in its pentavalent form (arsenate), and reduction of arsenate to arsenite is mediated through glutathione. Body attempts to detoxify the agent via repeated oxidative methylation and reduction reaction, leading to the generation of methylated metabolites, which are excreted in the urine. Understandably the detoxification/bio-inactivation process is not a complete defense against the vicious metalloid, and it can cause chromosomal aberration, impairment of DNA repair process, alteration in the activity of tumor suppressor gene, etc., leading to genotoxicity and carcinogenicity. Arsenic causes apoptosis via free radical generation, and the cutaneous toxicity is linked to its effect on various cytokines (e.g., IL-8, TGF-beta, TNF-alpha, GM-CSF), growth factors, and transcription factors. Increased expression of cytokeratins, keratin-16 (marker for hyperproliferation) and keratin-8 and -18 (marker for less differentiated epithelial cells), can be related to the histopathological findings of hyperkeratosis and dysplastic cells in the arsenicosis skin lesion.

Quality of life in psoriasis: A study from south India

Abstract: Background: Psoriasis can have a profound impact on a patient's quality of life. Very few Indian studies have examined this aspect of Indian patients of psoriasis. Aims: This study was conducted to assess the clinical severity, as well as physical and psychosocial disability, and stress incurred and to analyze their interrelationship in psoriasis patients aged more than 18 years. Methods: This hospital-based cross-sectional study was conducted in the Department of Dermatology, JIPMER, Pondicherry, India. Clinical severity, physical and psychosocial morbidity, and the stress incurred were measured using psoriasis area severity index (PASI), psoriasis disability index (PDI), and psoriasis life stress inventory (PLSI) respectively, the latter two of which were suitably modified and translated into the local language, viz., Tamil. Appropriate tests were conducted using SPSS for Windows (Release 7.5.1) statistical software. Results: Fifty patients (34 males, 16 females) were included in the study. The clinical PASI scores correlated significantly with the overall physical disability (PDI), individual aspects of the PDI (except the treatment-related activities), and the measurement of stress incurred (PLSI). A PASI score of more than 18 delineated a subgroup of patients with higher overall physical disability and higher stress rating. Among the physical and psychosocial factors investigated, daily activities, employment, and treatment were reported to be affected the most. Psoriasis sufferers are also most likely to feel self-conscious, be disturbed / inconvenienced by the shedding of the skin, live in a constant fear of relapse, and avoid social interactions. Conclusions: The present study provides compelling evidence that psoriasis affects the quality of life, and it highlights the importance of adopting a multidimensional assessment of psoriasis.

Chronic idiopathic urticaria: comparison of clinical features with positive autologous serum skin test.

Abstract: Background: Chronic idiopathic urticaria (CIU), in its extremely severe form, can pose a therapeutic challenge to the treating physician. It has been noted that in one third of such patients, autoantibodies against the IgE receptor are seen and such patients have more severe and unremitting urticaria. Aim: To compare clinical features of autoimmune urticaria with those of other CIU patients. Methods: We conducted a prospective study in an attempt to correlate the clinical features with autoantibodies, indirectly detected via the autologous serum skin test (ASST), which is the simplest and the best in vivo clinical test for detection of basophil histamine-releasing activity. Discussion: Out of 100 patients with chronic idiopathic urticaria, 34 showed a positive reaction to the autologous serum skin test and it was found that the frequency and severity of attacks was higher in these patients. Conclusion: ASST may be used as a simple and cost-effective test for the classification of chronic urticaria, which has proven to be a therapeutic challenge to the treating physician.

Homocystinuria due to cystathionine beta synthase deficiency.

Abstract: A two year-old male child presented with cutis marmorata congenita universalis, brittle hair, mild mental retardation, and finger spasms. Biochemical findings include increased levels of homocysteine in the blood-106.62 micromol/L (normal levels: 5.90-16 micromol/L). Biochemical tests such as the silver nitroprusside and nitroprusside tests were positive suggesting homocystinuria. The patient was treated with oral pyridoxine therapy for three months. The child responded well to this therapy and the muscle spasms as well as skin manifestations such as cutis marmorata subsided. The treatment is being continued; the case is reported here because of its rarity. Homocysteinuria arising due to cystathionine beta-synthase (CBS) deficiency is an autosomal recessive disorder of methionine metabolism that produces increased levels of urinary homocysteine and methionine It manifests itself in vascular, central nervous system, cutaneous, and connective tissue disturbances and phenotypically resembles Marfan's syndrome. Skin manifestations include malar flush, thin hair, and cutis reticulata / marmorata.

A clinicopathologic study of skin appendageal tumors

Abstract: Background: Appendageal skin tumors belong to a heterogenous group of tumors with specific histopathology. The aim of this study is to determine the pattern of appendageal tumors in skin biopsies done in our department. Methods: This is a 3-year retrospective descriptive study of all patients who were diagnosed to have skin appendageal tumors in our department, and the diagnoses were confirmed by histopathology. The tumors were classified as eccrine, hair, sebaceous, and apocrine after a detailed examination of routine hematoxylin and eosin sections. Results: The total number of cases in the study was 33 - 10 males and 23 females. Tumors with eccrine differentiation constituted the maximum, 17 cases (51.5%); followed by tumors with hair differentiation, 12 cases (36.36%); tumors with sebaceous differentiation, 2 cases (6.06%); and apocrine tumors, 2 cases (6.06%). Syringoma constituted the commonest eccrine tumor, 14 cases (42.42%); while trichoepithelioma was the commonest hair tumor, 9 cases (27.27%). The other eccrine tumors were eccrine spiradenoma, 2 cases (6.06%); and nodular hidradenoma, 1 (3.03%). The other hair tumors were pilar cyst, 2 (6.06%); and pilomatricoma, 1 (3.03%). The sebaceous tumors constituted 2 cases (6.06%) of nevus sebaceous. Syringocystadenoma papilliferum, 1 (3.03%); and cylindroma, 1 (3.03%), constituted the apocrine tumors. Conclusions: Appendageal skin tumors are relatively uncommon. Histopathology is mandatory for the diagnosis. No tumor showed malignant change in this study.

A study of oxidative stress in paucibacillary and multibacillary leprosy.

Abstract: Background: The study and assessment of oxidative stress plays a significant role in the arena of leprosy treatment. Once the presence of oxidative stress is proved, antioxidant supplements can be provided to reduce tissue injury and deformity. Aim: To study oxidative stress in paucibacillary (PB) and multibacillary (MB) leprosy and to compare it with that in a control group. Methods: Fifty-eight untreated leprosy patients (23 PB and 35 MB cases) were studied and compared with 58 healthy controls. Superoxide dismutase (SOD) level as a measure of antioxidant status; malondialdehyde (MDA) level, an indicator of lipid peroxidation; and MDA/SOD ratio, an index of oxidative stress were estimated in the serum. Results: The SOD level was decreased in leprosy patients, especially in MB leprosy. The MDA level was increased in PB and MB leprosy. The MDA/SOD ratio was significantly elevated in MB patients. There was a steady increase in this ratio along the spectrum from tuberculoid to lepromatous leprosy (LL). Conclusion: There is increased oxidative stress in MB leprosy, especially in LL. This warrants antioxidant supplements to prevent tissue injury.

Standard guidelines of care for acne surgery.

Abstract: Acne surgery is the use of various surgical procedures for the treatment of postacne scarring and also, as adjuvant treatment for active acne. Surgery is indicated both in active acne and post-acne scars. Physicians' qualifications: Any Dermatologist can perform most acne surgery techniques as these are usually taught during postgraduation. However, certain techniques such as dermabrasion, laser resurfacing, scar revisions need specific hands-on training in appropriate training centers. Facility: Most acne surgery procedures can be performed in a physician's minor procedure room. However, full-face dermabrasion and laser resurfacing need an operation theatre in a hospital setting. Active acne: Surgical treatment is only an adjunct to medical therapy, which remains the mainstay of treatment. Comedone extraction is a process of applying simple mechanical pressure with a comedone extractor, to extract the contents of the blocked pilosebaceous follicle. Superficial chemical peel is a process of applying a chemical agent to the skin, so as to cause controlled destruction of the epidermis leading to exfoliation. Glycolic acid, salicylic acid and trichloroacetic acid are commonly used peeling agents for the treatment of active acne and superficial acne scars. Cryotherapy: Cryoslush and cryopeel are used for the treatment of nodulocystic acne. Intralesional corticosteroids are indicated for the treatment of nodules, cysts and keloidal acne scars. Nonablative lasers and light therapy using Blue light, non ablative radiofrequency, Nd:YAG laser, IPL (Intense Pulsed Light), PDT (Photodynamic Therapy), pulse dye laser and light and heat energy machines have been used in recent years for the treatment of active inflammatory acne and superficial acne scars. Proper counseling is very important in the treatment of acne scars. Treatment depends on the type of acne scars; a patient may need more than one type of treatment. Subcision is a treatment to break the fibrotic strands that tether the scar to the underlying subcutaneous tissue, and is useful for rolling scars. Punch excision techniques such as punch excision, elevation and replacement are useful for depressed scars such as ice pick and boxcar scars. TCA chemical reconstruction of skin scars (CROSS) (Level C) is useful for ice pick scars. Resurfacing techniques include ablative methods (such as dermabrasion and laser resurfacing), and nonablative methods such as microdermabrasion and nonablative lasers. Ablative methods cause significant postoperative changes in the skin, are associated with significant healing time and should be performed by dermatosurgeons trained and experienced in the procedure. Fillers are useful for depressed scars. Proper case selection is very important in ensuring satisfactory results.

Diagnosing multibacillary leprosy: a comparative evaluation of diagnostic accuracy of slit-skin smear, bacterial index of granuloma and WHO operational classification.

Abstract: Background: In view of the relatively poor performance of skin smears WHO adopted a purely clinical operational classification, however the poor specificity of operational classification leads to overdiagnosis and unwarranted overtreatment while the poor sensitivity leads to underdiagnosis of multibacillary (MB) cases with inadequate treatment. Bacilli are more frequently and abundantly demonstrated in tissue sections. Aims and Methods: We compared WHO classification, slit-skin smears (SSS) and demonstration of bacilli in biopsies (bacterial index of granuloma or BIG) with regards to their efficacy in correctly identifying multibacillary cases. The tests were done on 141 patients and were evaluated for their ability to diagnose true MB leprosy using detailed statistical analysis. Results: A total of 76 patients were truly MB with either positive smears, BIG positivity or with a typical histology of BB, BL or LL. Amongst these 76 true-MB patients, WHO operational classification correctly identified multibacillary status in 56 (73.68%), and SSS in 43 (56.58%), while BIG correctly identified 65 (85.53%) true-MB cases. Conclusion: BIG was most sensitive and effective of the three methods especially in paucilesional patients. We suggest adding estimation of bacterial index of granuloma in the diagnostic workup of paucilesional patients.

Contact with armadillos increases the risk of leprosy in Brazil: a case control study.

Abstract: Background: Mycobacterium leprae infection has recently been detected in wild armadillos in Brazil. Leprosy is still endemic in Brazil and although its transmission is mostly by person-to-person contact, many cases report no history of previously known leprosy contact. It has been suggested that other sources of M. leprae may contribute to the transmission of leprosy in some areas. Aim: Our objective was to investigate whether contact with armadillos is associated with leprosy. Methods: A case-control study was carried out in Brazil. Data was collected from 506 leprosy patients and 594 controls on exposure to armadillos and age, sex, place of birth and living conditions. Univariate analysis and unconditional logistic regression were conducted to investigate whether leprosy was associated with exposure to armadillos. Results: Direct armadillo exposure was reported by 68% of leprosy cases and by 48% of controls (P < 0.001) roughly doubling the risk of leprosy, with odds ratio (OR) 2.0, 95% confidence interval (CI) [1.36-2.99]. Conclusion: The results of this study suggest that direct exposure to armadillos is a risk factor for leprosy in Brazil.

Goldenhar syndrome with unusual features.

Abstract: We report here the case of a 17 year-old girl with the classic signs of Goldenhar syndrome in the form of multiple accessory tragi, bilateral ocular dermoids, mandibular hypoplasia (micrognathia) and cervical lordosis She also had a high arched palate, gingival hypertrophy and malaligned teeth, features which are as yet unreported

Basic digital photography in dermatology

Abstract: Digital photography has virtually replaced conventional film photography as far as clinical imaging is concerned. Though most dermatologists are familiar with digital cameras, there is room for improvement in the quality of clinical images. We aim to give an overview of the basics of digital photography in relation to dermatology, which would be useful to a dermatologist in his or her future clinical practice.

Incidence of pemphigus in Thrissur district, south India

Abstract: Background: Pemphigus is a common autoimmune blistering disorder in India. However, there are no population based surveys from India available to study the prevalence of this disease. Aims: To estimate the incidence of pemphigus in Thrissur district, Kerala, South India. Methods: Questionnaire based survey was conducted among the practicing dermatologists of Trichur district between 1 st January 2001 and 1 st January 2002 to determine the incidence of pemphigus in the district. Results: Ten cases of pemphigus vulgaris, one case of pemphigus erythematosus, and two cases of pemphigus foliacious were diagnosed during the study period in a population of 2.9 million in Thrissur district. The average age of pemphigus vulgaris patients was 58years in males [42 to 82 years] and 37 in females [25 to 57 years]. The average age of the two male pemphigus foliacious patients was 46 years [52 and 40 years] and the only pemphigus erythematosus patient was a 45 year-old female.Five cases of pemphigus vulgaris were investigated clinically histopathologically and by using direct immunofluorescence, while two were investigated clinically and histopathologically, two cases clinically, and one case clinically and with Tzanck smear. Two cases ofpemphigus foliacious were diagnosed with the aid of direct immunofluorescence and the only case of pemphigus erythematosus was diagnosed with the aid of direct immunofluorescence. Pemphigus vulgaris was common among females. The incidence of pemphigus in Thrissur district is 4.4 per million. Conclusions: This study indicates that the incidence of pemphigus in Thrissur district is high in comparison to the available studies from Germany, France, and the North African country Tunisia.

Diffuse cutaneous leishmaniasis: co-infection with human immunodeficiency virus (HIV).

Abstract: Cutaneous leishmaniasis is a disease caused by intracellular protozoal parasites belonging to the genus Leishmania. Immune suppression caused by HIV infection is an important factor for atypical presentation and widespread progression of cutaneous leishmaniasis. Diffuse (disseminated) cutaneous leishmaniasis and HIV co-infection is emerging as an extremely serious new disease. A 38-year-old HIV-positive man presented with a 12-month history of a progressive papule and nodular eruptions on face and extremities with infiltrations of nasal and oral mucosa. We report the case due to its atypical, widespread muco-cutaneous presentation masquerading as lepromatous leprosy.