Analyzing the clinical efficacy and safety of levocetirizine based on its receptor occupancy, intraclass comparison and role in the treatment of CSU: an AROG consensus statement.

INTRODUCTION: Chronic spontaneous urticaria (CSU) is characterized by urticaria persisting for more than 6 weeks. Antihistamines, notably sgAH (second generation antihistamines) are the first line of treatment for CSU. AREAS COVERED: This consensus aimed to review the existing research on receptor occupancy of antihistamines, including levocetirizine, and translate its implications in the treatment of CSU. The consensus deliberations were under the banner of the Antihistamine Receptor Occupancy Group (AROG) from India, an expert panel of 12 dermatologists with a mix of institutional and practitioner backgrounds. This group analyzed the existing translational research on the receptor occupancy of levocetirizine to establish the clinical efficacy and safety of levocetirizine in the treatment of CSU using the grading of recommendations assessment, development, and evaluation (GRADE) method vis-a-vis the varied SGAH. EXPERT OPINION: SGAH constitute the first step in the therapeutic ladder for managing CSU. Levocetirizine has high bioavailability, high affinity and occupancy of the H1 receptor, rapid onset of action, limited distribution and minimal hepatic metabolism. It exhibits significant anti-inflammatory effects at clinically relevant concentrations. The marked receptor occupancy translates to enhanced efficacy as compared to similarly dosed SGAH with the lower cost making it an appropriate drug for chronic use. Receptor occupancy should be the basis of intra-class head-to-head trials in CSU.

Hypothalamus-pituitary-adrenal axis (HPA axis) suppression with inappropriate use of steroids in recalcitrant dermatophytosis - A cross-sectional study.

Background: Improper use of over-the-counter (OTC) steroid medication has been linked to recalcitrant dermatophytosis. There is proven evidence of HPA axis suppression by the use of long-term oral steroids. This study aims to determine the prevalence and pattern of inappropriate OTC steroid use and its effects on the hypothalamus-pituitary-adrenal (HPA) axis in adults with recalcitrant dermatophytosis. Materials and Methods: This cross-sectional study of 2 months was conducted in a hospital setting and included patients of recalcitrant dermatophytosis with a history of OTC steroid use. Clinico-demographic details and basal serum cortisol levels were recorded in all and analyzed. Result: Of a total of 103 patients, 59.22% (n = 61/103) were males, and the mean duration of steroid abuse was 17.78 months. About 48.54% (n = 50/103), 3.88% (n = 4/103), and 47.57% (n = 49/103) patients reported the use of topical steroids, oral steroids, and both oral and topical steroids, respectively. Among all the topical steroid users (n = 99), clobetasol propionate 48.48% (n = 48/99), while among oral steroid users (n = 53), prednisolone 45.28% (n = 24/53) were the most commonly used agents, respectively. The morning serum cortisol levels (8-9 AM) were found to be decreased in 42.7% (n = 44/103), with a mean value of 44.28 ± 17.34 µg/dL. Conclusion: Improper OTC steroid use in recalcitrant dermatophytosis leads to HPA axis suppression. This highlights the need for intervention from apex health officials.

Quality of Life in Psoriasis: A Cross-Sectional Study from North India.

Background: Psoriasis is a chronic inflammatory papulo-squamous disease characterized by multiple remissions and relapses. This study aimed to assess the impact of psoriasis on the quality of life of patients. Materials and Methods: A hospital-based, cross-sectional study was conducted enrolling 198 adult patients of psoriasis. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for observational studies were followed. Clinical severity of psoriasis was measured using Psoriasis Area Severity Index (PASI), and quality of life was measured by EuroQoL 5D (EQ-5D-5L, EQ-VAS) and Psoriasis Quality-Of-Life-12 (PQOL-12) Questionniares. Results: Of the 198 patients, 71.7% (n = 142/198) were males with a mean age of 41.65 ± 13.19 years. The mean PASI score was 12.46 ± 11.51, and the mean PQOL-12 score was 50.18 ± 23.36. Up to 22.7% (n = 45) cases had 'severe' and 6.1% (n = 12) cases has 'very severe' PQOL-12 scores. Statistically significant correlation (P < 0.05) was observed between PASI scores and almost all domains of EQ-5D-5L and PQOL-12. Conclusion: Psoriasis affects most psycho-social domains of a patient's life. Coping with these QOL issues remains a challenge to the patients in everyday life. The goal of management of psoriasis therefore must include measures to improve quality of life along with long-lasting remittance of physical symptoms.

Oral isotretinoin with desloratadine compared with oral isotretinoin alone in the treatment of moderate to severe acne: a randomized, assessor-blinded study.

BACKGROUND: Our aim was to measure the effectiveness of oral isotretinoin with desloratadine compared with oral isotretinoin alone in treating moderate to severe acne at a tertiary care teaching hospital in North India. In this study, 90 patients with moderate to severe acne were enrolled to participate based on their fulfilling the inclusion criteria. METHODS: A randomized, assessor-blinded, parallel-arm study was conducted. Randomization was done using computer-generated tables to allocate treatments in a 1:1 ratio. A low-dose oral isotretinoin at a dose of 0.3 mg/kg/day with tab desloratadine at 5 mg/day was applied to the study group and compared against the same patients going without the dosage when controls were conducted. Follow-up was at 4, 8, and 12 weeks. RESULTS: The primary outcome was an improved global acne grading system (GAGS) score and decreased acne lesion count. SECONDARY OUTCOME: patient satisfaction with treatment. The 90 participants were randomized and 15 participants dropped out of the study, leaving 75 participants for intention to treat analysis (n = 41, n = 30). At week 12, the GAGS score and acne lesion count between the study and control groups were comparable (P > 0.05). Pruritus reported was 9.76% in the study versus 33.33% in the control group (P = 0.018). Also, 53.66% of participants reported "excellent" treatment satisfaction in the study group versus 36.67% in the control group. CONCLUSIONS: The addition of desloratadine to an isotretinoin regimen has a role in reducing disease and therapy-related pruritus in acne and leads to improved patient satisfaction.

Mucocutaneous Findings in Hematolymphoid Neoplasms: An Observational Study.

Background: Cutaneous manifestations of hematological neoplasms can be divided into three broad categories - direct infiltration, paraneoplastic conditions, and those due to the treatment of hematological cancers. Objectives: To study the frequency and patterns of mucocutaneous manifestations in patients with hematolymphoid neoplasms and those due to chemotherapy. Materials and Methods: This was an observational study done with 172 patients. Categorization of mucocutaneous manifestations was done into malignancy-associated and chemotherapeutic drugs-associated and data was analyzed. Results: Out of a total of 172 patients, 15.6% (27/172) had malignancy-related mucocutaneous manifestations. Among these, 4.6% (8/172) had direct infiltration of malignant cells into the skin and 11% (19/172) had paraneoplastic manifestations. The most common chemotherapy-related mucocutaneous manifestations were nail changes - 47.1% (81/172), of which transverse melanonychia was the most common (20.9%). About 44.2% (76/172) had a cutaneous infection, the commonest of which was a fungal infection (15.1%). Chemotherapy-induced alopecia was noted in 46.5% (80/172) and found to be significantly associated with cytarabine, daunorubicin, doxorubicin, methotrexate, and vincristine. Cutaneous hyperpigmentation was found to be significantly associated with cytarabine, doxorubicin, and vincristine. Conclusion: Mucocutaneous manifestations cause additional discomfort to a patient undergoing chemotherapy. Early recognition and timely and appropriate management facilitate symptom control and prevent treatment-related morbidity. A multidisciplinary approach involving hemato-oncologists and dermatologists can help achieve this target.

The Voice of the Lost Toe: Pseudo-Ainhum Beyond Skin.

An 11-year-old boy presented with serial autoamputations of the right 4th and 5th toes during the past 6 years. This was associated with sensory loss on the right leg and development of constriction bands around the right 2nd and 3rd digits for the past 5 months. For a year, the patient had been treated with paucibacillary, multi-drug therapy (PB-MDT) with a presumptive diagnosis of leprosy. He was born from a nonconsanguinous marriage and the birth was uneventful. The developmental milestones were normal, and no family history of any congenital anomalies was reported.

Systemic treatments in Parthenium dermatitis: A systematic review and meta-analysis.

Parthenium dermatitis is the commonest form of plant dermatitis in India, caused by the plant Parthenium hysterophorus. Systemic immunosuppressives are commonly employed in its treatment. However, there is a relative lack of comparative head-to-head trials. This study was done to assess the relative efficacy and safety of systemic treatments in Parthenium dermatitis. We systematically reviewed all the published studies investigating the safety and efficacy of systemic treatments for Parthenium dermatitis in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and clinical trial registries. Treatment benefit data were tabulated based on outcome measures of scoring systems. The quality of evidence for each outcome was assessed by Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria for meta-analysis. The pooled Standardized mean difference (SMD) for case series and comparative studies based on clinical severity score (CSS) for azathioprine was 4.007 (95% CI (Confidence interval): 3.141, 4.873) and 0.746 (95% CI: 0.139, 1.352), respectively. About 88.8% (95% CI: 76.8%, 100.8%, p = 0.076) of the patients had excellent or a good response to azathioprine. Our meta-analysis shows that azathioprine has the highest level of evidence in the treatment of Parthenium dermatitis.

Epidermoid Cyst: An Esthetic Challenge, If Neglected-A Comprehensive Analysis of 217 Cases.

Background: An epidermoid cyst is a benign keratin-filled cyst, commonly located in the face, scalp, neck, and trunk. Although it is a common benign cystic neoplasm, large series of analyses in English literature are still scarce. To comprehend the clinical and pathological variation of epidermoid cysts in the sub-Himalayan region of India, as well as their clinical implications for late diagnosis, a retrospective study on epidermoid cysts was conducted. Materials and Methods: This was a retrospective observational study conducted on 217 cases of epidermoid cyst subjected for fine-needle aspiration cytology over a period of 3.6 years (from 2018 to 2021). The clinical details and other epidemiological data were archived from the pathology requisition forms. Results: It showed slight male preponderance with head and neck site as the most common area. Most patients were adults. Few uncommon sites were also seen namely breast, parotid, epididymis, and tonsils. Few large lesions were identified measuring up to 10 cm. The skin changes were seen in 5.5% cases, 0.9% cases show extreme ulceration, and 4.1% cases show foreign body giant cell reactions. Due to the province's steep terrain and limited access to medical services, the majority of patients arrived at out patient department (OPD) late. Conclusion: The findings suggest that fine-needle aspiration can be used as a quick diagnostic test even in remote areas by the general practitioner who can send the slides for evaluation to a pathologist. Many times, clinically looking epidermoid cyst can reveal certain challenging entities such as a biphasic fibroepithelial tumor with cystic squamous metaplasia and proliferating pilar tumor in our series. The study of this lesion is also needed for early diagnosis as long-standing lesion may rupture and cause requirement of extensive treatment followed cosmetic impairment.

Rescue treatment with intravenous immunoglobulin and amniotic membrane dressing in refractory paediatric pemphigus vulgaris with sepsis.

We report a case of refractory paediatric pemphigus vulgaris with sepsis, treated successfully with intravenous immunoglobulin (IVIG) and amniotic membrane dressing. The patient was initially started on oral prednisolone (1 mg/kg/day) and dapsone 50 mg once daily. Azathioprine 50 mg orally was then used in place of dapsone due to rapid disease progression with extensive skin involvement. However, the patient developed sepsis and azathioprine had to be discontinued. Because of rapidly progressive disease and sepsis, the patient was put on IVIG at a dose of 2 g/kg in divided doses over 3 days along with amniotic membrane dressing. There was marked improvement after 2 weeks of follow-up.

Steroid abuse, quality of life, and various risk factors in dermatophytosis: a cross-sectional observational study from a tertiary care center in northern India.

INTRODUCTION: Dermatophytosis is a superficial cutaneous mycosis and is steadily progressing to epidemic proportions in India. Various factors such as steroid overuse and misuse are currently making its treatment challenging. The study examines various sociodemographic characteristics, clinical factors, and steroid abuse in patients with dermatophytosis and also assess their quality of life (QOL). METHODS: A hospital­based cross­sectional study was carried out for a period of 1 year among adult patients with dermatophytosis after obtaining informed written consent. Sociodemographic and clinical details were recorded, and QOL was assessed with the Dermatology Life Quality Index (DLQI) questionnaire. RESULTS: Among 550 patients analyzed, the most common dermatophytosis was tinea (n = 408/550, 74.18%), dominated by tinea cruris and tinea corporis. Steroid abuse was frequent (n = 511/550, 92.90%), the most common being clobetasol propionate (n = 26/52, 50%). Hypopigmentation and atrophy were the most common side effects (53.52%). The mean DLQI was 14.44 ± 7.29 in males and 15.78 ± 6.26 in females. DLQI scores were statistically influenced (p < .05) by steroid abuse, low socioeconomic status, young adult status, widespread tinea, and poor hygiene. CONCLUSION: Dermatophytosis was found to have a significant adverse impact on QOL. As seen in this study, the widespread abuse of steroids may be a leading cause of the emergence of recalcitrant tinea in India.