Dermoscopic Findings and Assessment of Treatment Response in Patients with Tinea Incognito: A Pilot Study.

Background: Tinea incognito presents with atypical, widespread, and recurrent lesions. Dermoscopy can aid its rapid diagnosis. Aim and Objectives: This study aimed at assessing dermoscopic features and response to treatment in patients with tinea incognito. Materials and Methods: An evaluation of 62 patients with tinea of glabrous skin (Group A (cases)-31 steroid modified and Group B (controls)-31 treatment naïve) was done. Clinical, dermoscopic, and mycological evaluations were done for both groups at baseline, 2, and 4 weeks of terbinafine therapy. Clinical severity (Clinical Assessment Severity Score (CASS) and Visual Analogue Scale (VAS)) and frequency of various dermoscopic changes were compared at 0 and 4 weeks between cases and controls, using unpaired Student's t-test, Mann-Whitney U-test, and Wilcoxon signed-rank test. Results: Baseline dermoscopic features for both groups were significantly different with respect to frequency of broken hair, bent hair, micropustules and Morse code hair. Earliest feature to resolve with treatment was micropustules at 2 weeks. Significant reduction in frequency of morphologically altered hair was evident at 4 weeks. Telangiectasia, dotted vessels, I-hair, and broken hair persisted for a longer period of time. Terbinafine for 4 weeks was an effective treatment, producing complete cure in 73% of cases and 93% of controls. Persistent dermoscopic changes at 2 weeks were found to be associated with treatment failure at 4 weeks, highlighting the role of dermoscopy in identifying patients requiring prolonged treatment. Conclusions: Dermoscopy can be used as a diagnostic and monitoring tool for tinea of glabrous skin.

Impact of COVID-19 Pandemic on Dermatology Teaching Program in India: A Survey on the Faculty and Residents' Perspective.

Background: Impact of COVID-19 pandemic has been immense. An innocent casualty of this disaster is medical education and training. Dermatology, which primarily deals with out-patient services, medical and surgical interventions, and in-patient services, was one of the worst hit. The National Medical Commission of India has implemented competency-based medical education (CBME) in Dermatology, Venereology, and Leprosy since 2019. The new curriculum relies on acquiring practical and procedural skills, training skills in research methodology, professionalism, attitude, and communication. Objectives: The study was undertaken to understand the implications of the COVID-19 pandemic on postgraduate dermatology CBME training in India. Materials and Methods: A questionnaire-based survey was carried out on postgraduate dermatology teachers and residents in India after obtaining ethics committee approval. An online semi-structured English questionnaire was administered by Google Forms. The calculated sample size was 366 dermatology faculty and 341 postgraduate students. Validity (Content validity ratio (CVR) ≥0.56) and reliability (Cronbach's alpha coefficient 0.7249) of the questionnaire were determined. Results: Among the 764 responses received, 51.4% reported that their institutes were converted to exclusive COVID hospitals. Domains of dermatology education affected were procedural training (n = 655), bedside clinical teaching (n = 613), outpatient department-based clinical teaching (n = 487), bedside laboratory procedures (n = 463), research activities (n = 453), histopathology (n = 412), and theory classes (n = 302). To keep up with the teaching-learning process, online platforms were mostly utilized: Zoom Meeting (n = 379), Google Meet (n = 287), and WhatsApp Interaction (n = 224). Teaching during ward rounds was significantly more affected in exclusively COVID institutes than non-exclusive COVID institutes (P < 0.001). Psychomotor skill development suffered a major jolt with 26.7% of respondents reporting a standstill (P < 0.001). Communication skills among students suffered due to social distancing, mask, and poor attendance of patients. According to 23.84% of respondents, formative assessment was discontinued. Conclusion: Online seminars, journal clubs, and assessments have been incorporated during the pandemic. Online modalities should be used as a supplementary method as psychomotor skills, communication skills, research work, and bedside clinics may not be replaced by the e-learning.

Developing Standard Treatment Workflows-way to universal healthcare in India.

Primary healthcare caters to nearly 70% of the population in India and provides treatment for approximately 80-90% of common conditions. To achieve universal health coverage (UHC), the Indian healthcare system is gearing up by initiating several schemes such as National Health Protection Scheme, Ayushman Bharat, Nutrition Supplementation Schemes, and Inderdhanush Schemes. The healthcare delivery system is facing challenges such as irrational use of medicines, over- and under-diagnosis, high out-of-pocket expenditure, lack of targeted attention to preventive and promotive health services, and poor referral mechanisms. Healthcare providers are unable to keep pace with the volume of growing new scientific evidence and rising healthcare costs as the literature is not published at the same pace. In addition, there is a lack of common standard treatment guidelines, workflows, and reference manuals from the Government of India. Indian Council of Medical Research in collaboration with the National Health Authority, Govt. of India, and the WHO India country office has developed Standard Treatment Workflows (STWs) with the objective to be utilized at various levels of healthcare starting from primary to tertiary level care. A systematic approach was adopted to formulate the STWs. An advisory committee was constituted for planning and oversight of the process. Specialty experts' group for each specialty comprised of clinicians working at government and private medical colleges and hospitals. The expert groups prioritized the topics through extensive literature searches and meeting with different stakeholders. Then, the contents of each STW were finalized in the form of single-pager infographics. These STWs were further reviewed by an editorial committee before publication. Presently, 125 STWs pertaining to 23 specialties have been developed. It needs to be ensured that STWs are implemented effectively at all levels and ensure quality healthcare at an affordable cost as part of UHC.

Deregulated phenotype of autoreactive Th17 and Treg clone cells in pemphigus vulgaris after in-vitro treatment with desmoglein antigen (Dsg-3).

The loss of balance between regulatory T (Treg) and T helper 17 (Th17) causes loss of tolerance against desmoglein (Dsg)-3 leading to pemphigus vulgaris (PV), an autoimmune bullous skin disorder associated with autoantibodies against Dsg-3. We aimed to elucidate the complex relationship of Th17 and Treg cells, their molecules, and the underlying mechanism in the development of PV disease. Using cytokine secretion assays, Th17 and Treg cells were sorted by FACS Aria-III within Dsg-3-responsive PBMC population and homogeneous T cell clones were generated in-vitro. Different cell surface molecules like CD25, GITR, CD122, CD152, CD45RO, IL-23R, STAT3, STAT5, CD127, HLA-DR, CCR4, CCR5, CCR6 and CCR7 were studied. The functional response of Th17 and Treg cells were elucidated by measuring the levels of various cytokines released by IL-10 and IL-17 T cells. The mRNA expression of transcription factors (FoxP3 and RORγt) was also analyzed. IL-17 secreting (Th17) cells with phenotype CD4+IL-17+ were greatly increased and IL-10 secreting (Treg) cells with phenotype CD4+IL-10+ were reduced in PV cases than healthy controls. The qPCR analysis showing high expression of retinoic acid receptor-related orphan receptor gamma (RORγt) mRNA in comparison to forkhead box P3 (FoxP3) mRNA confirmed the development of pro-inflammatory Th17 response in PV. Further, the cytokine profile of pro-inflammatory and anti-inflammatory cytokines suggested defective suppressive functions in Treg cells with high inflammatory response. Our findings indicate that autoantigen Dsg-3 specifically allows the proliferation of IL-17 secreting T cells though has a negative effect on IL-10 secreting T cells leading to dysregulation of immunity in PV patients. This antagonistic relationship between Dsg-3-specific Th17 and Treg cells may be critical for the onset and persistence of inflammation in PV cases.

Review on host-pathogen interaction in dermatophyte infections.

Dermatophytosis is a common superficial fungal infection of the skin and its appendages caused by dermatophytes. Recent times have witnessed a dynamic evolution of dermatophytes driven by their ecology, reproduction, pathogenicity and host immune response, influenced by population migration and socioeconomic status. Dermatophytes establish infection following successful adherence of arthroconidia to the surface of keratinized tissues. The proteolytic enzymes released during adherence and invasion not only ascertain their survival but also allow the persistence of infection in the host. While the cutaneous immune surveillance mechanism, after antigen exposure and presentation, leads to activation of T lymphocytes and subsequent clonal expansion generating effector T cells that differentially polarize to a predominant Th17 response, the response fails to eliminate the pathogen despite the presence of high levels of IFN-γ. In chronic dermatophytosis, antigens are a constant source of stimulus promoting a dysregulated Th17 response causing inflammation. The host-derived iTreg response fails to counterbalance the inflammation and instead polarizes to Th17 lineage, aggravating the chronicity of the infection. Increasing antifungal resistance and recalcitrant dermatophytosis has impeded the overall clinical remission. Human genetic research has the potential to generate knowledge to explore new therapeutic targets. The review focuses on understanding specific virulence factors involved in pathogenesis and defining the role of dysregulated host immune response against chronic dermatophytic infections for future management strategies.

A Snapshot of T Cell Subset Cytokines in Pemphigus Vulgaris: A Cross-Sectional Study.

OBJECTIVE: The purpose of this study was to assess the serum levels of cytokines produced by the Th1 (IFN-γ, IL-12), Th2 (IL-4), Th17 (IL-6, IL-17A, IL-23), and Treg (IL-10 and TGF-ß) pathways in individuals with active pemphigus vulgaris (PV) and to determine whether these levels were correlated with the severity of the disease condition. PATIENTS AND METHODS: This study was conducted with 90 individuals, of which 50 were PV patients and 40 healthy individuals (age and gender-matched) as controls. Serum samples were collected and tested for cytokine levels by ELISA (enzyme-linked immunosorbent assay). The cytokine levels in the serum of PV patients and healthy controls were compared statistically using the Mann-Whitney test for nonparametric samples. The strength of the association between the variables was evaluated using the Spearman correlation test. RESULTS: The mean serum levels of IFN- γ (p < 0.001), IL-6 (p < 0.001), IL-10 (p < 0.001), IL-12 (p < 0.05), and IL-17 (p < 0.001) were significantly higher and TGF-ß were significantly low in the PV patients than those observed in the control group. The mean concentration of serum IL-4 in patients with PV did not differ from those in the control group. CONCLUSIONS: In active PV, the Th1 and Th17 pathways are involved in the development and progression of the disease, whereas the Th2 pathway is blocked. Both of these pathways play a significant role in the disease. It is possible that the Treg pathway acts as an antagonist to the Th1 and Th17 pathways, which would cause the disease to become more localised. This study lays the foundation for a better understanding of the aetiology of PV and implies that cytokines could be used as potential therapeutic targets and disease activity biomarkers.

Nail Changes in COVID-19: A Cross Sectional Study From India.

Background: Various nail manifestations have been reported with COVID-19; mostly in the form of isolated reports. Objective: This cross-sectional study was carried out to assess nail changes in hospitalized patients with moderate to severe COVID-19. Methods: Nail findings in 43 adults being treated for COVID-19, were evaluated after obtaining informed written consent. Nail changes involving fingernails and toenails were documented as new-onset or pre-existing changes. Disease status, hematological and biochemical tests, inflammatory markers, treatment administered and outcomes were also recorded. The frequency of changes in fingernails and toenails were statistically compared. Results: The red half-moon sign (32.5%) and nail bed erythema (34.8%) were the commonest changes seen in fingernails; while apparent leukonychia (46.5%) and distal brown discoloration (51.1%) were commonest changes in toenails. The difference in frequency of changes seen between fingernails and toenails was statistically significant (p < 0.05). Nail changes correlated with systemic involvement in these patients. Limitations: Single-center evaluation in a limited number of patients, without using augmented examination techniques like onychoscopy, nail fold capillaroscopy, or fluoroscence. Those with less severe disease or with rapid fatality could not be studied. Conclusion: Nail changes in COVID-19 are common and reflect the systemic nature of illness, being a harbinger of underlying complications.

Clinicoepidemiological characteristics of cutaneous tuberculosis in 1458 Indian patients: a retrospective analytical study from a tertiary care center.

BACKGROUND: Tuberculosis (TB) has been one of the most challenging infectious diseases globally. Cutaneous tuberculosis (CTB) accounts for 0.5-2% of extrapulmonary TB and is often missed owing to its varying morphology and paucibacillary nature. METHODS: In this retrospective analytical study, we share our 22-year experience to describe the clinicoepidemiological features and treatment response of CTB in 1458 Indian patients. In each patient, detailed history was followed by clinical examination, hematological and biochemical investigations, Mantoux testing, chest x-ray, and other specialized investigations to detect coexisting systemic foci. Clinical diagnosis of CTB was confirmed on histopathology/cytology and response to standard antitubercular treatment (ATT). All details were recorded on a predesigned proforma. RESULTS: Of 1458 eligible patients, 803 were children. The mean disease duration was 15.3 months. Lupus vulgaris (40.4%) was the most common clinical variant, followed by scrofuloderma (32.7%) and lichen scrofulosorum (15.2%). Other variants included tuberculosis verrucosa cutis, gumma, tuberculids, and inoculation TB. Multiple clinical variants were observed in 3.6% of patients. A total of 41.4% of patients had coexistent systemic foci; in lymph nodes (50.4%), lungs (35.6%), bone (10.3%), and abdomen (5.8%). TB foci were also observed at uncommon locations like the eye, central nervous system, and genital organs. Treatment response to ATT was favorable in 99.2%. INTERPRETATION: The burden of CTB still persists in developing countries. The diagnosis is often missed due to the wide spectrum of clinical and histological presentations. Awareness among clinicians of varying aspects of CTB is of paramount importance for early diagnosis and management and will significantly prevent morbidity and disease complications.

Evaluation of hTERT Gene Expression and Chromosome 7 Copy Number Variation in Anal Squamous Intra-Epithelial Lesions: A Pilot Study.

Background: Akin to cervical squamous intra-epithelial neoplasia (CIN), anal squamous intra-epithelial lesion (a-SIL) is attributed to persistent infection with high-risk human papilloma virus infection. Amplification of human telomerase reverse transcriptase (hTERT) gene and aneuploidy are known to correlate with CIN evolution. It is plausible that the underlying genetic events in a-SIL are similar. We conducted this cross-sectional analytical study with the objective of determining expression of hTERT gene expression and chromosome 7, as marker of cell ploidy in a-SIL. Methods: Conventional anal cytology was performed in 86 adult consenting subjects with history of receptive anal intercourse (RAI) and 4 controls without history of RAI. Cases with a-SIL and controls were subjected to fluorescent in-situ hybridization (FISH) to evaluate hTERT gene and chromosome 7 expression, as marker of cell ploidy. Results were expressed as number of abnormal nuclei (≥3 respective signals), maximum degree of amplification, mean signals/nucleus and proportion of cases showing abnormal nuclei. Results: Twenty cases showed a-SIL; with 15 atypical squamous cells of undetermined significance (ASCUS), 3 low grade squamous intra-epithelial lesion (LSIL) and 2 cases of high-risk cytology. Expression of both hTERT gene and chromosome 7 increased from controls to ASCUS to LSIL with concomitant increase in proportion of cases having abnormal hTERT gene and chromosome 7 expression. Conclusions: Positive association of hTERT gene with a-SIL suggests its possible role in evolution of anal squamous abnormalities. Increase in chromosome 7 also correlated positively with a-SIL. These findings corroborate the similarities between squamous carcinogenesis in CIN and a-SIL.

Clinico-epidemiological profile of lichen scrofulosorum: a 22-year, single-center, retrospective study.

BACKGROUND: Lichen scrofulosorum (LS) represents immunologic reaction to the Mycobacterium tuberculosis antigen and presents with subtle, asymptomatic, grouped follicular papules over the trunk and shows good therapeutic response to antitubercular drugs. OBJECTIVE: To study the clinical and epidemiological characteristics of patients diagnosed with LS. MATERIALS AND METHODS: A single-center retrospective review of patients diagnosed with LS from 1997 to 2018 was conducted. The data pertained to clinico-epidemiological profile, BCG vaccination, Mantoux positivity, laboratory investigations, coexistent focus of tuberculosis, and response to antitubercular treatment (ATT). RESULTS: LS cases constituted 15.2% (221/1458) of all the patients diagnosed with cutaneous tuberculosis (CTB). Of these, 156 (70.5%) were pediatric patients. All patients presented with multiple follicular and perifollicular grouped papules. The trunk was the most common site involved (98.6%), followed by lower limb (25.33%), upper limb (15.83%), face (5%), and external genitalia (3.6%). Evidence of BCG vaccination and Mantoux test positivity was observed in 52.03 and 83.2%, respectively. Coexistent TB focus was detected in 134 (60.6%) patients in lymph nodes, lungs, abdomen, and unusual sites such as intracranial, endometrium, and eye. Twenty-eight patients (12.66%) had coexistent other clinical forms of CTB. Clinical diagnosis of LS was confirmed on histology that revealed chiefly periappendageal epithelioid cell granuloma. Response to ATT was good with complete resolution of lesion in 8-12 weeks. CONCLUSION: LS appears to be an underdiagnosed entity. Subtle and asymptomatic lesions of LS are often missed, thereby necessitating a high index of suspicion and appropriate evaluation of the underlying TB focus.

Trichoscopy as a monitoring tool in assessing treatment response in 98 children with tinea capitis: A prospective clinical study.

Tinea capitis (TC) is the most common dermatophyte infection in children. Fungal culture the gold standard diagnostic method takes several weeks and has poor yields. Trichoscopy helps in rapid diagnosis and could work as a monitoring tool during antifungal therapy. Our main objective is to document the evolution of trichoscopic features with treatment and their correlation with clinical parameters in patients of TC. Forty-six and 52 children with clinically diagnosed TC that was confirmed by potassium hydroxide microscopy, received griseofulvin and terbinafine, respectively. Recruited children were subjected to clinical and trichoscopic assessment by calculation of CASS (clinical assessment severity score) and counting of TAHC (Total Altered hair count; negative and positive), respectively, at baseline and follow-up at 2, 4, and 6 weeks. McNemar, Wilcoxon singed ranked test and Spearman-rho correlation of various parameters was evaluated. Follow-up trichoscopy revealed significant (p < 0.009) disappearance of negative TAHC like black dot (second week onward), corkscrew, horseshoe and zigzag hair at 4 weeks and short broken hair, erythema telangiectasia hemorrhage (ETH) resolved at 6 weeks. Positive TAHC (regrowing hair) shows significant increase at 6 weeks (p < 0.001). CASS and negative TAHC showed significant difference at 4 weeks (p < 0.001) by analyzing boxplot graph. Therefore, trichoscopic resolution occurred before the clinical cure. Terbinafine subjects showed a higher clinical cure rate at 4 weeks (p = 0.02) as compared to griseofulvin. To conclude, trichoscopy is a good monitoring tool that could document the disappearance of almost all dystrophic hair at 4 to 6 weeks and is a more sensitive tool than microscopic examination. Regrowing hair and perifollicular scaling are markers of recovery.

Transgenders are the most vulnerable amongst individuals engaging in receptive anal intercourse: A cross-sectional study from North India.

Background: In India, sexuality not confirming to hetero-conjugal and peno-vaginal norm is abhorred and discriminated against. Individuals engaging in Receptive Anal Intercourse (RAI) are marginalized. Reappraisal of their sexual health conditions is likely to promote inclusive health care. Methods: Eighty-five consenting adults with RAI history were recruited from a tertiary care hospital in Delhi. Clinico-demographic data was noted and anal cytology samples were reported by Bethesda 2014 terminology. Results: There were 29 transgenders (TGs), 51 males (31 bisexual) and five females. Fifty-four subjects were Human Immunodeficiency Virus (HIV) infected (22 TGs, 31 males (17 bisexual) and one female) and 52 were receiving anti-retroviral treatment (ART). Thirty-one subjects had anal warts (6 TGs, 20 males, five females). Anal cytology revealed squamous intra-epithelial lesions (SIL) in 20 (5 TGs, 13 males, two females). TGs had significantly risker sexual practices than homosexual males, bisexual males and females, with consistently earlier age of first RAI exposure and frequent childhood (≤16 years) RAI experience compared to homosexual males, bisexual males and females, even after stratification by HIV status, warts and SIL. Conclusions: TGs had the highest sexual health risk profile including higher frequency of HIV infection compared to other subjects with RAI history. Bisexuality was common; their risk profile was variably lower than homosexual males. Mindfulness of above is likely to help overcome barriers to health care access and promote compassionate approach at all levels including primary care physicians.

Role of Trichoscopy in the Management of Tinea Capitis in Two Infants: A Case Report.

As tinea capitis rarely affects infants, early trichoscopic diagnosis facilitates timely institution of appropriate therapy. We report a 10-month-old female presenting with mixed pattern tinea capitis and coexisting tinea faciei wherein trichoscopy showed perifollicular scaling, comma hair, corkscrew hair, and horse-shoe hair. Case 2 was a 3-month-old female with gray patch tinea capitis, corroborated by the presence of perifollicular scaling, comma hair, corkscrew hair, and prominent telangiectasia on trichoscopy. Both cases were successfully treated with tablet fluconazole (5 mg/kg) for 6-8 weeks.

Recommendations for COVID Vaccination for Dermatological Patients on Immunosuppressive/Immunomodulatory Therapy (IADVL Academy).

Significant proportion of patients with dermatological disorders are on immunosuppressive or immunomodulatory therapy predisposing them to risk of acquisition of COVID-19 infection. However, the efficacy of COVID-19 vaccination among these patients is a matter of concern due to lack of adequate evidence for their protective effect owing to the drug induced immunosuppressed state. Hence, we from the IADVL academy have framed the recommendations to be followed for COVID-19 vaccination among dermatological patients on immunosuppressive therapy based on available related literature.