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Showing papers in "Indian Journal of Dermatology, Venereology and Leprology in 2021"


Journal ArticleDOI
TL;DR: In this article, the authors discuss the epidemiology and clinical features of the contemporary problem of dermatophytosis in India and suggest that the clinical distribution is marked by a disproportionate rise in the number of cases with tinea corporis and cruris, cases presenting with the involvement of extensive areas and tinea faciei.
Abstract: Dermatophytosis has attained unprecedented dimensions in recent years in India. Its clinical presentation is now multifarious, often with atypical morphology, severe forms and unusually extensive disease in all age groups. We hesitate to call it an epidemic owing to the lack of population-based prevalence surveys. In this part of the review, we discuss the epidemiology and clinical features of this contemporary problem. While the epidemiology is marked by a stark increase in the number of chronic, relapsing and recurrent cases, the clinical distribution is marked by a disproportionate rise in the number of cases with tinea corporis and cruris, cases presenting with the involvement of extensive areas, and tinea faciei.

48 citations


Journal ArticleDOI
TL;DR: A systematic review and meta-analysis were performed focusing on the Severity of Alopecia Tool 50 achievement rate, the frequency of adverse events and recurrence after discontinuation of treatment.
Abstract: Background Tofacitinib and ruxolitinib have been used off-label to treat alopecia areata. Although a number of case reports and small studies have been published, there are no comprehensive reviews examining the outcomes of using tofacitinib and ruxolitinib for the treatment of alopecia areata. Aims The aim of the study was to examine the outcome of patients with alopecia areata treated with oral tofacitinib or ruxolitinib in previously published studies. Methods A search of MEDLINE, Embase and Cochrane library was conducted. A systematic review and meta-analysis were performed focusing on the Severity of Alopecia Tool 50 achievement rate, the frequency of adverse events and recurrence after discontinuation of treatment. Results A total of 1244 studies were identified of which only 12 studies met the inclusion criteria. Of the 346 patients in these 12 studies, 288 had received oral tofacitinib and 58 had received oral ruxolitinib. The overall Severity of Alopecia Tool50 achievement rate was 66% (95% confidence interval, 54%-76%). Subgroup analysis revealed that drug choice, mean age, sex ratio and alopecia areata subtype ratio did not significantly affect the treatment response. Infections and laboratory abnormalities were the most common adverse events (98 and 65 cases of 319 patients, respectively). Patients treated for more than six months had a greater frequency of laboratory abnormalities as compared to those treated for shorter durations (24% vs. 7%; P = 0.04). Recurrence of alopecia areata was observed within three months after discontinuation of treatment in the majority (74%) of patients. Limitations This analysis was limited by the small number of observational studies available for review, the heterogeneity of patient characteristics and the lack of long-term data. Conclusion Both oral tofacitinib and ruxolitinib are effective and well tolerated in the treatment of alopecia areata. Clinicians should be aware of the expected efficacy, adverse events and high recurrence rate of oral JAK inhibitors for alopecia areata to effectively counsel these patients before starting therapy.

15 citations


Journal ArticleDOI
TL;DR: In this paper, the authors proposed a method to evaluate the upper limit of a minimal inhibitory concentration of wild type isolates for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility.
Abstract: One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance between in vivo and in vitro resistance, demonstration of in vitro resistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.

12 citations


Journal ArticleDOI
TL;DR: The shift in the predominant agent of dermatophytosis from T. rubrum to T. mentagrophytes, within a relatively short span of time, is without historic parallel, and the apparent ease of transmission of a zoophilic fungus among human hosts can also be explained by means of mycological phenomena.
Abstract: Trichophyton (T.) mentagrophytes now accounts for an overwhelming majority of clinical cases in India, a new "Indian genotype" (T. mentagrophytes ITS genotype VIII) having been isolated from skin samples obtained from cases across a wide geographical distribution in this country. The conventional diagnostic methods, like fungal culture, are, however, inadequate for diagnosing this agent. Thus, molecular methods of diagnosis are necessary for proper characterization of the causative agent. The shift in the predominant agent of dermatophytosis from T. rubrum to T. mentagrophytes, within a relatively short span of time, is without historic parallel. The apparent ease of transmission of a zoophilic fungus among human hosts can also be explained by means of mycological phenomena, like anthropization.

12 citations


Journal ArticleDOI
TL;DR: Oral submucous fibrosis is one of the commonest precancerous conditions of the oral mucosa involving any part of the internal cavity resulting in tissue scarring, dysphagia and trismus as mentioned in this paper.
Abstract: The oral cavity is considered to be a mirror of the body’s health, as it reflects the manifestations of various systemic disorders. Most of the oral mucosa is derived embryologically from an invagination of ectoderm and thus, like other similar orifices, it may become involved in the disorders that are primarily associated with the skin. Oral submucous fibrosis is one of the commonest precancerous conditions of the oral mucosa involving any part of the oral cavity resulting in tissue scarring, dysphagia and trismus. It is a collagen-related disorder characterized by excessive fibrosis in the oral submucosa, hyalinization and degenerative changes in the muscles. This disease has become a challenging entity for dermatologists due to resemblance of its features to various mucocutaneous conditions. An improper diagnosis can lead to wrong treatment and additional complications. Dermatologists need to be aware of the characteristic features of this disease which can distinguish it from other similar conditions. This review aims to focus on the detailed aspects of oral submucous fibrosis including its historical background, etiological factors, pathogenesis, clinical features, differential diagnosis, investigations, management and future perspectives.

11 citations


Journal ArticleDOI
TL;DR: Salicylic acid peel is a cheap and useful option in the treatment of dermatophytic infection and indicates that 4 weeks' treatment is not sufficient in some patients to eradicate fungus and may require longer treatment.
Abstract: Background Treatment of dermatophytosis is becoming costlier and challenging. Aims and objectives To study the efficacy of salicylic acid peel in dermatophytosis. Methods Twenty-five patients (20 males and 5 females) having dermatophytosis with positive potassium hydroxide (KOH) mounts were enrolled in the study. Salicylic acid 30% was applied over the lesions weekly for 4 weeks, thereafter patients were followed up weekly for 4 weeks. Results Of the 25 patients, 22 (88%) patients showed clinical and microbiological cure 1 week after the last application, while the remaining 3 patients were nonresponders. Nine (41%) patients of the 22 responders showed recurrences indicating that 4 weeks' treatment is not sufficient in some patients to eradicate fungus and may require longer treatment. Limitations A relatively small sample size and lack of long-term follow-up are the shortcomings of our study. Conclusion Salicylic acid peel is a cheap and useful option in the treatment of dermatophytic infection.

10 citations


Journal ArticleDOI
TL;DR: In this article, the effectiveness and safety of topical timolol in the treatment of early pyogenic granulomas was evaluated using a two-centre, double-blind and placebo-controlled trial.
Abstract: Introduction Pyogenic granulomas are benign vascular lesions of the skin and mucosa which are often a source of concern because of their recurrent bleeding even with minimal trauma. Current treatment for pyogenic granuloma is ablative; no medical therapy is standardized to date. Timolol, due to its vasoconstrictive effect, vascular growth factor inhibition and apoptosis promotion properties, is a potential therapeutic option. Objectives To assess the effectiveness and safety of topical timolol in the treatment of pyogenic granulomas. Methods A two-centre, double-blind and placebo-controlled trial (Registration CTRI/2019/04/018581) was conducted. Patients of either sex were recruited with pyogenic granuloma lesions of less than eight weeks duration. Topical treatment with 0.5% timolol or matching glycerin placebo was continued for six weeks. Changes in color, size, bleeding tendency, physicians' and patients' global assessments and adverse events were assessed. Results Forty subjects were randomized between the two groups which were comparable in age, sex, duration of illness and baseline lesion size.Significant improvement was noted with timolol, with color change from first follow-up onwards and lesion size reduction from second follow-up onward. Patients' assessment of bleeding tendency also showed imrovement from the second visit onward. Between-group comparison showed significant difference with respect to percentage reduction in size (timolol 40.9%, placebo 3.4%; P = 0.002). Rescue treatment (electrosurgery) was required in five patients on placebo and in one in the timolol group (P = 0.182). Complete resolution occurred in 2 (10%) patients with timolol and in no patients on placebo (P = 0.231). Limitations We observed effects of treatment for only six weeks. Conclusion Topical timolol may be a treatment option for early pyogenic granulomas but complete resolution is unlikely in six weeks. Studies of longer duration are required to assess resolution and recurrence rates.

8 citations


Journal ArticleDOI
TL;DR: It is demonstrated that photodynamic diagnosis combined with reflectance confocal microscopy can be used for the noninvasive diagnosis of subclinical extramammary Paget's disease and may be used to guide strategies for planning treatment and preventing relapse.
Abstract: Extramammary Paget's disease is a rare skin malignancy, and its diagnosis requires invasive biopsy and histopathological examination. Surgery is the standard treatment for extramammary Paget's disease patients; however, as incision boundaries and the depth of tumor cell infiltration are often unclear, the postoperative recurrence rate is high. We present a case in which we used photodynamic diagnosis in combination with reflectance confocal microscopy before surgery to detect an extramammary Paget's disease lesion that was located 3 cm away from the classical lesion. This secondary lesion exhibited a subclinical presentation, and it was eventually confirmed as an extramammary Paget's disease lesion by pathological examination. During detection using our technique, we delineated the boundaries of the extramammary Paget's disease lesion as a guide for surgical excision. The findings of our case demonstrate that photodynamic diagnosis combined with reflectance confocal microscopy can be used for the noninvasive diagnosis of subclinical extramammary Paget's disease and may be used to guide strategies for planning treatment and preventing relapse.

8 citations


Journal ArticleDOI
TL;DR: Biologics produce rapid improvement in skin and joint symptoms in chronic reactive arthritis, but the response is not long-lasting, and the number of treatment switches increased with the follow-up duration.
Abstract: Background Patients with reactive arthritis frequently present to dermatologists. However, there is paucity of information regarding its clinical aspects and management in dermatological literature. Objective To review the clinical features and management of patients with chronic reactive arthritis admitted to the dermatology department of a teaching hospital. Methods This was a retrospective analysis of patients with reactive arthritis admitted to the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India from January 2016 to February 2018. Results There were 12 males (disease duration 9-180 months). Biologics were used in 9 (75%) patients on 16 different occasions, the most frequent being infliximab (n = 10 times), followed by adalimumab (n = 3), etanercept, secukinumab and itolizumab (n = 1 each), in combination with other systemic agents. Response rate with treatment regimens including biologics (69% responders, 31% partial responders) was statistically significantly better than those without biologics (27% responders, 46% partial responders, 27% nonresponders; P = 0.036), using a composite measure assessing improvement in skin and joint symptoms. Biologics were discontinued on 50% of the occasions, after a median of 3.5 months (range 1.5-7.5 months) because of satisfactory response (n = 4), therapeutic fatigue (n = 3) or adverse event (n = 1). After biologic discontinuation, the response was sustained for a median of 5 months (range 3-6 months) before disease exacerbation. The number of treatment switches increased with the follow-up duration (median three switches per patient, range 1-8). The median follow-up duration was 10.5 months (range 4-76 months). Conclusion Biologics produce rapid improvement in skin and joint symptoms in chronic reactive arthritis, but the response is not long-lasting. Patients with chronic reactive arthritis have a waxing and waning course despite regular treatment. Limitations The limitations are retrospective design, small sample size and lack of a validated outcome measure.

8 citations


Journal ArticleDOI
TL;DR: In this paper, the authors compared the sensitivity of clinical examination and high-resolution ultrasound in detecting peripheral nerve thickening in leprosy cases, and found that high resolution ultrasound showed greater sensitivity than clinical examination.
Abstract: Background: Detection of peripheral nerve thickening and nerve function impairment is crucial in the diagnosis and the management of leprosy. Aims and objectives: (1) To document the cross-sectional area, echotexture and blood flow of peripheral nerves in healthy controls and leprosy cases using high-resolution ultrasound, (2) to compare the sensitivities of clinical examination and high-resolution ultrasound in detecting peripheral nerve thickening in leprosy. Methods: Peripheral nerves of 30 leprosy patients and 30 age- and sex-matched controls were evaluated clinically and by high-resolution ultrasound. When the cross-sectional area of a peripheral nerve on high-resolution ultrasound in a leprosy patient was more than the calculated upper bound of the 95% confidence interval for mean for that specific nerve in controls, that particular peripheral nerve was considered to be enlarged. Results: Cross-sectional areas more than 7.1 mm2 for the radial nerve, 8.17 mm2 for ulnar, 10.17 mm2 for median, 9.50 mm2 for lateral popliteal and 11.21mm2 for the posterior tibial nerve were considered as nerve thickening on high-resolution ultrasound. High-resolution ultrasound detected 141/300 (47%) nerves enlarged in contrast to the 60 (20%) diagnosed clinically by palpation (P < 0.001). Clinical examination identified thickening in 31/70 (44.3%) nerves in cases with impairment of nerve function and 29/230 (12.6%) in the absence of nerve function impairment. High-resolution ultrasound detected thickening in 50/70 (71.4%) nerves with impairment of function and in 91/230 (39.6%) nerves without any impairment of function. Limitation: A single-centre study design was the major study limitation. Conclusion: High-resolution ultrasound showed greater sensitivity than clinical examination in detecting peripheral nerve thickening in leprosy cases. High-resolution ultrasound, may therefore improve the sensitivity of the diagnostic criterion of peripheral nerve enlargement in the diagnosis and classification of leprosy.

8 citations



Journal ArticleDOI
TL;DR: In this paper, the authors evaluated the association between carotid intima-media thickness and epicardial fat thickness in psoriasis patients and healthy controls, and found that the latter was positively correlated with the former.
Abstract: Background: Carotid intima-media thickness test is a surrogate marker of subclinical atherosclerosis. Epicardial fat thickness is an early marker of coronary artery disease. Several studies have noted that psoriasis patients have an increased risk of coronary artery disease. In the present study, we attempted to see any variation in carotid intima-media thickness and epicardial fat thickness in psoriasis patients when compared to controls. Aims: 1) To determine the carotid intima-media thickness and epicardial fat thickness in psoriatic patients and healthy controls. 2) To evaluate the association between carotid intima-media thickness and epicardial fat thickness in psoriasis patients. Methods: A hospital-based study with 100 subjects (50 with psoriasis and 50 healthy controls) was conducted in the Dermatology Outpatient Department of Justice KS Hegde Charitable Hospital, a unit of KS Hegde Medical Academy affiliated to NITTE (Deemed to be University) Mangaluru. A detailed history and examination including body mass index, psoriasis area and severity index were done. Carotid ultrasound was done to measure carotid intima-media thickness and transthoracic echocardiography was done to assess epicardial fat thickness in both cases and controls. Independent sample t-test, Pearson rank correlation (r) coefficient were used for statistical analysis. P-value <0.05 was considered statistically significant. IBM Statistical Package for the Social Sciences version 22 Armonk, NY: IBM Corp was used for statistical analysis. Results: Mean carotid intima-media thickness in the right carotid ([0.51 ± 0.1mm vs 0.47 ± 0.1 mm] [P = 0.038]) and left carotid ([0.53 ± 0.12 mm vs 0.48 ± 0.1 mm] [P = 0.041]) were significantly increased in psoriasis patients than in controls. Mean epicardial fat thickness was significantly increased ([1.76 ± 0.66 mm vs. 1.49 ± 0.47 mm] ([P = 0.020]) in patients with psoriasis when compared with the controls. Epicardial fat thickness was positively correlated with carotid intima-media thickness in patients with psoriasis. Limitations: The cross-sectional design of the study, smoking among study subjects, inter and intraobserver variability of measurement of epicardial fat thickness and carotid intima-media thickness. Conclusion: Carotid intima-media thickness and epicardial fat thickness were increased in psoriasis patients when compared with healthy controls. Epicardial fat thickness was positively correlated with carotid intima-media thickness in cases.

Journal ArticleDOI
TL;DR: In this paper, the authors characterized the clinical profile of childhood leprosy presenting at tertiary leprose care hospitals in the states of Bihar, West Bengal and Uttar Pradesh in India, and to determine the possible risk factors associated with disabilities at presentation.
Abstract: OBJECTIVES The objectives of the study were to characterize the clinical profile of childhood leprosy presenting at tertiary leprosy care hospitals in the states of Bihar, West Bengal and Uttar Pradesh in India, and to determine the possible risk factors associated with disabilities at presentation. METHODS Subjects were children with newly diagnosed leprosy registered for treatment at tertiary Leprosy Mission Hospitals in Muzaffarpur (Bihar), Purulia (West Bengal) and Faizabad (Uttar Pradesh), India, between June and December 2019. Demographic and leprosy characteristics were collected at the time of diagnosis. Parents/guardians were interviewed on reasons for delay in presenting at the hospital. Associations between various factors and delay in diagnosis were assessed. RESULTS Among the 84 children, the mean (SD) age was 10 (3) years with a range of 4-14 years. There were more boys (58%) and most children were currently in school (93%), resident in rural areas (90%) and belonged to a lower socioeconomic status (68%). More children were diagnosed with multibacillary leprosy (69%), one-third of them being skin smear positive for Mycobacterium leprae. On presentation, 17% had deformity (5% grade 1 deformity and 12% grade 2), 29% had nerve involvement and skin lesions were spread across the body in half of the children. Mean (SD) duration of delay was 10.5 (9.8) months. Delayed presentation was more in boys (43% vs. 17%; P = 0.01), those without a history of migration for work compared to those who had a history of migration (40% vs. 9%; P = 0.008) and in those children who were from a poor economic status compared with those that came from a better economic status (44% vs. 7%; P = 0.001) Limitations: Because our study was conducted at tertiary care hospitals, the findings are not representative of the situation in the field. Furthermore, a comparison group of newly diagnosed adult leprosy patients with disability could have been included in the study. CONCLUSION Childhood leprosy continues to occur in endemic pockets in India and a substantial number present with skin smear positivity and deformity. Guardians of these children cite many reasons for the delay in presentation.

Journal ArticleDOI
TL;DR: In this article, the authors compared the efficacy and adverse effect profile of the standard recommended dose of MTX (i.e. 0.3mg/kg/week) versus a combination of reduced doses of methotrexate (MTX and cyclosporine (CsA) in patients with chronic plaque psoriasis.
Abstract: Background: Psoriasis is a chronic, inflammatory, relapsing and remitting disease with no cure till date. There is a paucity of trials using a combination of methotrexate (MTX) and cyclosporine (CsA) in chronic plaque psoriasis, due to fear of added toxicity, although they are time tested treatment options for monotherapy. Aims: The study aimed to compare the efficacy and adverse effect profile of the standard recommended dose of MTX (i.e. 0.3mg/kg/week) versus a combination of reduced doses of MTX and CsA (i.e. MTX 0.15 mg/kg/week with CsA 2.5mg/kg/day) in patients with chronic plaque psoriasis. Methods: Study design was a non-blinded randomised controlled trial. Patients of chronic plaque psoriasis with PASI more than 10 were randomised in 1: 1 allocation to receive either 0.3 mg/kg/week of intramuscular MTX injection or a combination of 0.15 mg/kg/week of intramuscular MTX injection and 2.5 mg/kg/day of CsA rounded off to the nearest 25 mg. Patients were followed up at every 2 weeks for 12 weeks. The doses were kept fixed throughout the study period. Results: A total of 66 patients received MTX monotherapy, whereas 67 patients received the combination. At baseline, both groups were comparable in their BSA (P = 0.105, Student t-test) and PASI (P = 0.277, Student t-test), which reduced significantly at 12 weeks in both groups (P < 0.001, paired t-test). The achievement of PASI-75 (P = 0.005), PASI-90 (P < 0.001) and PASI-100 (P = 0.001) was more in the combination group (Chi square test). Intention to treat analysis using Chi square test also showed better outcomes for PASI-75 (P = 0.027), PASI-90 (P < 0.001) and PASI-100 (P = 0.001) in the combination group. Combination group also had earlier onset of action (P = 0.001, Chi square test). There was no significant difference between the groups in terms of laboratory and clinical adverse events. Limitations: Non-blinded, no comparison with CsA monotherapy arm, no follow up beyond 12 weeks. Conclusion: The combination of reduced doses of MTX and CsA is more efficacious with earlier onset of action and similar adverse effects as with MTX monotherapy.

Journal ArticleDOI
TL;DR: The results suggest that topical latanoprost 0005% ophthalmic solution is less effective but safer than topical betamethasone dipropionate 005% lotion in the treatment of localized alopecia areata.
Abstract: Background Topical corticosteroids are the standard therapy for the treatment of alopecia areata Recently, topical latanoprost has been found effective in the treatment of eyelash alopecia areata Objectives The objective of this study was to compare the efficacy of topical latanoprost ophthalmic solution (group 1) with that of topical betamethasone diproprionate lotion (group 2) in the treatment of localized alopecia areata Methods This was a single-centre, randomized, two-armed, parallel-group efficacy trial Fifty consecutive patients with localized alopecia areata were randomized in a 1:1 ratio to receive either topical latanoprost 0005% ophthalmic solution or topical betamethasone diproprionate 005% lotion Of these 50 patients, 44 patients (21 in group 1 and 23 in group 2) completed the treatment protocol Results The percentage reduction in area involved with alopecia areata at 16 weeks (primary outcome) was lower in latanoprost vs betamethasone group (median [interquartile range], 111 [0-991] vs 100% [136-100], P = 002) Significantly lesser patients in the latanoprost group had a complete response to treatment as compared to the betamethasone group (6 [24%] vs 14 [56%], P = 002) The median (interquartile range) hair regrowth score was significantly lower in the latanoprost vs the betamethasone group (1 [0-45] vs 5 [1-5], P = 002) Subjects in the betamethasone group showed a more rapid reduction in the involved area Limitations Short duration of treatment and follow-up were limitations of this study Conclusion Our results suggest that topical latanoprost 0005% ophthalmic solution is less effective but safer than topical betamethasone dipropionate 005% lotion in the treatment of localized alopecia areata (clinicaltrialsgov: NCT02350023)

Journal ArticleDOI
TL;DR: A rare case of glucagonoma syndrome with necrolytic migratory erythema presenting as pruritic papules and follicular pustules in a 57-year-old woman; showing eosinophilic infiltration on histology.
Abstract: Necrolytic migratory erythema is most commonly associated with glucagonoma syndrome. We report a rare case of glucagonoma syndrome with necrolytic migratory erythema presenting as pruritic papules and follicular pustules in a 57-year-old woman; showing eosinophilic infiltration on histology. However, the final diagnosis was confirmed by demonstrating neuroendocrine tumour on histopathological examination of the liver metastases. Nutrition therapy was administered as a palliative treatment. This case also highlights the atypical clinical features and nonspecific histology of necrolytic migratory erythema which makes the diagnosis difficult.

Journal ArticleDOI
TL;DR: Patients who used topical steroids for dermatoses where it is an absolute contraindication, as well as those who developed side effects, were included in the study and the level of awareness among patients, pharmacists and general practitioners about commonly available topical steroids and its combinations was determined.
Abstract: Aims and objectives (1) To determine the level of awareness among patients, pharmacists and general practitioners about commonly available topical steroids and its combinations.(2) To determine the source of recommendation/prescription of topical steroids and its combination creams.(3) To know and create awareness about the side effects of topical steroids in all the study groups. Methods This was a prospective questionnaire-based study where three study groups, namely patients, pharmacists and general practitioners, were included. This study was approved by the institutional ethics committee. after ethical clearance. The patients who used topical steroids for dermatoses where it is an absolute contraindication, as well as those who developed side effects, were included in the study. ThoroughComplete cutaneous examination was done specifically to detect the side effects of steroids. Seminars were conducted and questionnaires were given to both the pharmacists and general practitioners of nearby areas. The questionnaire consisted of questions regarding their prescription and dispensing practices of topical steroids and its combinations. Results Out of 95 patients seen, the most commonly used steroid molecule was clobetasol propionate 0.05% in 44 (46.3%) patients, the common source of recommendation was general practitioners in 36 (37.8%), the common indication was superficial dermatophytosis in 85 (89%) and the most common adverse effect was recurrence/increase in the extent of the infection in 72 (75.78%) patients. Out of total 44 general practitioners enrolled in the study, 22 (50%) were qualified allopathic medical practitioners and22 (50%) were homeopathic/ayurvedic doctors. Superficial dermatophytosis [19 (43.18%)] was the common dermatosis seen by them. While 29 (65.90%) preferred prescribing topical steroids or its combination, rest of them preferred plain steroid creams. Out of 179 pharmacists, 74 (41.34%) did not have appropriate knowledge of topical steroids, 35 (19.55%) were not aware that steroids are isschedule "H" drugs. Commonest molecule sold over the counterwas clobetasol propionate 0.05% by 74 (41.89%). The limitations of our study were small study group and short duration. Conclusion As dermatologists, it is our responsibility, to correctly educate the society, particularly the non-dermatologist medical fraternity, about ethical and rational use of topical steroids.

Journal ArticleDOI
TL;DR: The results suggest that adalimumab is a treatment of choice for patients with concomitant hidradenitis suppurativa and psoriasis.
Abstract: Psoriasis and hidradenitis suppurativa are inflammatory dermatoses that have been associated with arthritis, metabolic syndrome, obesity, and smoking. They share common pathogenic mechanisms such as elevated levels of several proinflammatory cytokines including tumor necrosis factor (TNF), interleukin-17A, and impaired Notch pathway. Thus, treatments for both diseases are sometimes overlapping. Biological therapy such as adalimumab is effective for patients with hidradenitis suppurativa and psoriasis. Adalimumab is a monoclonal antibody that binds to TNF and inhibits the cytokine interaction with the TNF receptors, thus inhibiting the inflammatory cascade. Currently, data are lacking on the treatment for co-occurrence of psoriasis and hidradenitis suppurativa. This case series describes three patients with a diagnosis of concomitant psoriasis and hidradenitis suppurativa. In these cases, after 12 weeks of treatment with adalimumab 40 mg every other week, the average Psoriasis Area Severity Index score reduced from 21.4 to 2.9 for psoriasis, Hidradenitis Suppurativa-Physician's Global Assessment from 3.3 to 0.7, and pain Visual Analog Scale for hidradenitis suppurativa from 4.6 to 2. The results suggest that adalimumab is a treatment of choice for patients with concomitant hidradenitis suppurativa and psoriasis.

Journal ArticleDOI
TL;DR: In this paper, the authors used the Semmes-Weinstein monofilament to quantify the loss of sensation in leprosy lesions using the SVM to strengthen the clinical diagnosis mainly of macular forms.
Abstract: Introduction: Hypochromatic macules with altered sensitivity are the first manifestations of skin leprosy. Validation of this sensory loss assists in the confirmation of the clinical diagnosis. Aims: The aim of the study was to quantify the loss of sensation in leprosy lesions using the Semmes-Weinstein monofilament to strengthen the clinical diagnosis mainly of macular forms. Methods: Seventy-four hypochromatic macules in the macular leprosy subgroup, 27 typical borderline leprosy subgroup lesions and 49 macules of other macular dermatoses (non-leprosy group) were evaluated using the 0.05 g force Semmes-Weinstein monofilament to quantify the alteration of sensitivity within and outside of the lesions. The esthesiometric change index was established as the total number of points with altered sensation divided by the total number of tested points within the lesions to calculate the internal esthesiometric change index and outside the lesions to calculate the peripheral esthesiometric change index; these indexes were calculated for all groups. The difference (Δ) between the esthesiometric change indices of the lesional area and the adjacent skin was calculated for the leprosy and nonleprosy groups. Results: The percentage of points with touch sensitivity alterations within the macular and typical borderline leprosy lesions was higher in leprosy than in the non-leprosy group. The borderline and macular leprosy presented higher esthesiometric change index within injured areas than outside injured areas or in the nonleprosy group (P < 0.005). When internal esthesiometric change index values in the macular and borderline leprosy groups were higher than 0.53 and 0.5, respectively, the receiver operating characteristic curve showed 98% sensitivity and approximately 99% specificity for both groups (P < 0.0001). Regarding the difference between indices, borderline and macular leprosy had values that were higher and closer to one than in the nonleprosy group (P < 0.0001), with 100% sensitivity and 96.5% specificity for leprosy diagnosis when ΔLG was higher than 0.34. A limitation was the inability to perform a double-blind study. Conclusion: Semmes-Weinstein esthesiometry is a simple, useful and low-cost tool to quantify the focal alteration of cutaneous sensitivity to improve clinical leprosy diagnosis, especially for macular lesions.

Journal ArticleDOI
TL;DR: A detailed literature review of all the available treatment modalities of Darier disease, including those that are both surgical and non-surgical, to compare their efficacies and to propose a novel therapeutic approach is provided in this article.
Abstract: Darier disease (DD) is a rare type of inherited keratinizing disorder with no definitive therapeutic approach. The objective of this study is to provide a detailed literature review of all the available treatment modalities of Darier disease, including those that are both surgical and non surgical, to compare their efficacies and to propose a novel therapeutic approach. A complete search of the literature for all articles describing the different treatments of Darier disease, with no restrictions on patients' ages, gender or nationalities, was performed with the use of PubMed. A total of 68 articles were included in the study: 3 prospective studies, 44 case reports/case series and 21 letters/correspondences/clinical images. The treatments described were topical, oral or physical. Retinoids (isotretinoin, tazarotene and adapalene) and fluorouracil were the two most effective topical treatments. Oral retinoids were the most effective oral therapy and were prescribed in the cases of generalized Darier disease. For localized and resistant skin lesions, physical therapies including surgical excision, dermabrasion and CO2 laser ablation were the first line choices. Limitations of this article include the inability to verify the accuracy of the published data, the relatively small sample size, the absence of randomized controlled clinical trials and possible unidentified confounding factors in various studies. In every therapeutic approach to Darier disease, consideration of patient comorbidities, disease distribution, severity and treatment accessibility is essential. Large and randomized clinical trials are necessary for the comparison of the efficacy and the safety of all the treatments of Darier disease and settling a consensus for management.

Journal ArticleDOI
TL;DR: The use of cyclosporine can reduce mortality in TEN patients and other promising immunomodulators could be steroid+intravenous immunoglobulin combination and etanercept.
Abstract: Background Limited evidence is available about effectiveness and choice of immunomodulating treatment modalities for toxic epidermal necrolysis (TEN). Aims To compare the effectiveness of interventions to reduce mortality in patients of toxic epidermal necrolysis through network meta-analysis. Methods Studies were retrieved using PubMed, Google Scholar and Cochrane Database of Systematic Reviews from inception to September 18, 2018. Only English language articles were considered. Observational and randomized controlled studies having ≥ 5 TEN patients in each intervention arm were included. Two investigators independently extracted study characteristics, intervention details and mortality data. Bayesian network meta-analysis was performed using the Markov chain Monte Carlo (MCMC) approach through the random effect model. The ranking analysis was done to provide a hierarchy of interventions. The consistency between direct and indirect evidence was assessed through node spit analysis. The primary outcome was to compare the mortality [Odds ratio OR (95% credibility interval CrI)] among all treatment modalities of TEN. Results Twenty-four studies satisfying the selection criteria were included. The network analysis showed improved survival with cyclosporine as compared to supportive care [OR- 0.19 (95% CrI: 0.05, 0.59)] and intravenous immunoglobulin [OR- 0.21 (95% CrI: 0.05, 0.76)]. The hierarchy of treatments based on "surface under the cumulative ranking curves" (SUCRA) value were cyclosporine (0.93), steroid+intravenous immunoglobulin (0.76), etanercept (0.59), steroids (0.46), intravenous immunoglobulin (0.40), supportive care (0.34) and thalidomide (0.02). No inconsistencies between direct and indirect estimates were observed for any of the treatment pairs. Limitations Evidence is mainly based on retrospective studies. Conclusion The use of cyclosporine can reduce mortality in TEN patients. Other promising immunomodulators could be steroid+intravenous immunoglobulin combination and etanercept.

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TL;DR: Histopathology and direct immunofluorescence microscopy cannot differentiate between various entities of pemphigoid diseases and a multivariant approach using a BIOCHIP™ mosaic including salt-split skin followed by immunoblotting with dermal extract helps to identify the target antigen.
Abstract: Background: The pemphigoid group of diseases may present clinically and immunologically in a very similar fashion. Indirect immunofluorescence microscopy with readily available salt-split human skin in a BIOCHIP™ helps to classify these conditions as those with either with roof binding or floor binding of immunoreactants. Epidermolysis bullosa acquisita, anti-laminin 332 pemphigoid and anti-p200 pemphigoid show floor binding, while in the most frequent type of pemphigoid disease, bullous pemphigoid, epidermal side staining pattern is seen on salt-split skin Aims: The aim of the study was to detect the target antigens in sub-epidermal bullous diseases. Methods: Forty patients with bullous pemphigoid diagnosed by lesional histopathology and direct immunofluorescence microscopy were re-evaluated by a BIOCHIP™ mosaic containing both tissue substrates and recombinant target antigens. Sera with floor pattern staining on salt-split skin were further evaluated by immunoblotting with dermal extract. Results: Five patients with floor staining had anti-p200 pemphigoid. Limitations: We could not perform serration pattern analysis of direct immunofluorescence in our patients. Conclusion: Histopathology and direct immunofluorescence microscopy cannot differentiate between various entities of pemphigoid diseases. A multivariant approach using a BIOCHIP™ mosaic including salt-split skin followed by immunoblotting with dermal extract helps to identify the target antigen.

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TL;DR: In this paper, the effect of buffy coat inclusion after the first spin on the final platelet concentration in platelet-rich plasma was analyzed and compared with pure platelet and leukocyte-poor platelet.
Abstract: Introduction Platelet-rich plasma is an autologous blood preparation which is used in various medical specialties because of its regenerative properties. There is a wide variation in platelet-rich plasma preparation protocols and attaining the ideal platelet yield (>1 million platelets/μL) in a clinic setting can be challenging. We aimed at analyzing the centrifuge spin rates at which to attain an ideal platelet-rich plasma yield and also to study the effect of inclusion of the buffy coat after the first spin on the final platelet concentration in platelet-rich plasma. Methods Seventy-five whole blood samples were obtained and divided into two groups - (1) leukocyte-rich platelet-rich plasma group and (2) leukocyte-poor platelet-rich plasma group. Samples in both groups were centrifuged using the dual spin method, at one of three centrifugation speed combinations (initial "soft" spin and second "hard" spin speeds, respectively): (1) 100 g/400 g, (2) 350 g/1350 g and (3) 900 g/1800 g. Platelet, red blood cell (RBC) and white blood cell (WBC) counts in both groups were compared. Results The 100 g/400 g spin gave a high platelet yield (increase of 395.4 ± 111.1%) in the leukocyte-poor-platelet-rich plasma group, while in the leukocyte-rich platelet-rich plasma group both 100 g/400 g and 350 g/1350 g spins resulted in significantly higher yields with an increase of 691.5 ± 316.3% and 738.6 ± 193.3%, respectively. Limitations The study was limited by a smaller sample size in the pure platelet-rich plasma (leukocyte-poor platelet-rich plasma) group. Conclusion Ideal platelet yields can be achieved with both the 100 g/400 g as well as the 350 g/1350 g spins using the buffy coat inclusion method while the 100 g/400 g spin for "pure" platelet-rich plasma accomplishes a near-ideal platelet count with significantly reduced contamination with other cells.


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TL;DR: Education and counseling of family caregivers by various support groups such as Pemphigus Family Associations could be effective in improving the quality of life of the caregivers.
Abstract: Background and Aims: Pemphigus vulgaris is a rare autoimmune intraepidermal vesiculobullous disease involving the skin and mucosa. It impacts the quality of life of both patients and their families. Methods: A total of 70 patients with pemphigus vulgaris (either outpatient or hospitalized) were enrolled using the simple sampling method between 2016 and 2017 from the dermatology clinic at Faghihi Hospital, Shiraz, Iran. A validated Persian version of the Family Dermatology Life Quality Index (FLDQI) questionnaire was filled by a family caregiver. The questionnaire contained 10 items assessing the quality of life of the family. Demographic variables were recorded in a separate form. Results: The mean age of the patients was 51 ± 11.3 years and that of the family caregivers was 32 ± 8.8 years. The FLDQI score was higher (poorer quality of life) if the patient was male, older, had shorter disease duration or had fewer disease recurrences (P = 0.046, 0.01, 0.001 and >0.001, respectively). Higher scores were also obtained in the less-educated caregivers (P = 0.026) but there was no association with either gender or age (P = 0.399, 0.1). Conclusion: Pemphigus vulgaris significantly affects the Family Dermatology Life Quality Index. Education and counseling of family caregivers by various support groups such as Pemphigus Family Associations could be effective in improving the quality of life of the caregivers. Limitations: This study did not assess the effect of comprising domain analysis, severity of disease, patients’ Dermatology Life Quality Index (DLQI), mucosal involvement, response to treatment, outpatient or admitted status, socioeconomic status, or the quality of life among the various family members.

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TL;DR: In this paper, the authors evaluated selected serum mediators involved in the innate and adaptive immune responses to identify possible immunomarkers for Erythema nodosum leprosum (ENL).
Abstract: Background Erythema nodosum leprosum (ENL) is a frequent complication of multibacillary leprosy that can result in significant morbidity, including peripheral nerve damage and physical disability. The identification of possible serum markers could be a valuable tool for the early detection of ENL. Aims The purpose of this study was to evaluate selected serum mediators involved in the innate and adaptive immune responses to identify possible immunomarkers for ENL. Methods The levels of interleukin-2, interleukin-4, interleukin-6, interleukin-10, interleukin-17, interferon-γ, tumor necrosis factor, nitric oxide and anti-phenolic glycolipid-I antibodies were measured in the sera of leprosy patients with ENL [at the beginning of reaction (M0) and 1 month later (M1)], and then compared with the levels of the same markers in patients with untreated multibacillary leprosy without ENL (controls with leprosy: CTRL) and healthy individuals (healthy controls: CTRH). Results Significantly higher levels of serum interleukin-6 were observed in M0 than in CTRL. In addition, pairwise comparisons showed higher levels of interleukin-6 in M0 compared to M1. Levels of tumor necrosis factor were higher in M0 than in CTRL, with no significant difference between M0 and M1. There were no differences in the levels of interleukin-2, interleukin-4, interleukin-10, interleukin-17 or interferon-γ between groups. The CTRL group had higher levels of nitric oxide compared to M0 and M1. High levels of anti-phenolic glycolipid-I were observed in M0, M1 and CTRL than in CTRH. Limitations Three patients were not assessed at M1, decreasing the number of evaluated patients from 14 to 11. Conclusion High-serum levels of interleukin-6 were observed during ENL, primarily in patients with more severe reactions; levels decreased after specific therapy, suggesting a role for this cytokine in pathogenesis and its utility as an ENL biomarker. Further studies should explore whether interleukin-6 could also be used as a predictive marker for ENL or as a specific target for its treatment.

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TL;DR: In this article, the effectiveness and safety of weekly pulse doses of azathioprine and methotrexate for the treatment of chronic plaque psoriasis were compared in a randomized controlled trial.
Abstract: Background: Methotrexate is the most commonly used drug in the treatment of psoriasis with good efficacy and safety. Recently, weekly azathioprine pulse has been shown to be effective in this disease. Aim: The aim of this study is to compare the effectiveness and safety of weekly pulse doses of azathioprine and methotrexate for the treatment of chronic plaque psoriasis. Methods: In this randomized controlled trial, 80 patients with chronic plaque psoriasis were recruited. After detailed clinical and laboratory evaluation, patients were randomized to 2 groups to receive either weekly 300 mg azathioprine (n = 40) or 15 mg methotrexate every week (n = 40) for 20 weeks, following which the response to treatment and adverse effects were assessed. The patients were then followed up every 4 weeks for 3 months to determine any relapse. Results: Overall, 48 (60%) patients achieved PASI 75, while 36 (45%) and 59 (73.8%) patients achieved PASI 100 and 50, respectively. On intention to treat analysis, PASI ≥ 75 was achieved in 47.5% (19/40) patients in group 1 compared to 85% (34/40) patients in group 2 (p < 0.001). However, on per protocol analysis, PASI ≥ 75 was achieved in 86% (19/22) patients in group 1 and 92% (34/37) patients in group 2 (p = 0.497). Minor clinical and biochemical adverse effects were noted in both the groups, which were comparable. One (7.7%) patient in group 1 and 4 (17.4%) in group 2 relapsed during follow-up. Limitations: Limitations of study include small sample size and short follow-up. Conclusion: Weekly azathioprine pulse appears to be beneficial in the management of chronic plaque psoriasis. However, it is less effective than weekly methotrexate. It can thus be of use as a therapeutic option in patients with contraindication to methotrexate or other similar agents in this disease.



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TL;DR: A 6-year-old Cambodian boy living near river Mekong with contact history to chicken, dogs and cattle suffered from tinea faciei and capitis, and the first description of favus in a child due to this dermatophyte was described.
Abstract: Nannizzia (N.) incurvata (formerly Microsporum incurvatum) represents a geophilic dermatophyte which has been previously classified as belonging to the species complex of N. gypsea (formerly Microsporum gypseum). A 42-year-old Vietnamese female from Saxony, Germany, suffered from tinea corporis of the right buttock after she returned from a 2-week-visit to her homeland Vietnam. From skin scrapings of lesions, N. incurvata grew on Sabouraud's dextrose agar. Treatment by ciclopirox olamine cream twice daily for 4 weeks was successful. A 6-year-old Cambodian boy living near river Mekong with contact history to chicken, dogs and cattle suffered from tinea faciei and capitis. Symptoms of the favus-like tinea capitis and tinea faciei were erythema and scaly patches with areas of alopecia. N. incurvata grew on Sabouraud's dextrose agar. The boy was treated with oral terbinafine 125 mg daily, topical miconazole cream and ketoconazole shampoo. The symptoms healed within 4 weeks of treatment. Cultivation of the samples revealed growth of N. incurvata. For confirmation of species identification, the isolates were subject to sequencing of ITS (internal transcribed spacer) region of the rDNA, and addition of the "translation elongation factor 1 α" (TEF 1 α) gene. Sequencing of the ITS region showed 100% accordance with the sequence of N. incurvata deposited at the NCBI database under the accession number MF415405. N. incurvata is a rare, or might be underdiagnosed geophilic dermatophyte described in Sri Lanka and Vietnam until now. This is the first isolation of N. incurvata in Cambodia, and the first description of favus in a child due to this dermatophyte.