Therapeutic response of 70% trichloroacetic acid CROSS in atrophic acne scars.

BACKGROUND: Acne scarring is a common sequela of acne for which no single treatment method is uniformly effective. The chemical reconstruction of skin scars (CROSS) therapy using high-concentration trichloroacetic acid (TCA) has shown promise as a cheap, safe, and effective modality of treatment in acne scars. OBJECTIVE: To assess the therapeutic response of 70% TCA CROSS on atrophic acne scars and to evaluate the adverse effects of this therapy. MATERIALS AND METHODS: Fifty-three patients with postacne atrophic scars were treated with 70% of TCA focal application every 2 weeks by the CROSS technique and results evaluated on 3 parameters: physician assessment, patient assessment, and satisfaction level of patients, after a follow-up of 3 months. RESULTS: Good or excellent improvement (>50%) was seen in 66% of patients on physician and patient assessments. The patients were either very satisfied or satisfied in 81.1% of cases. Patients with predominantly boxcar scars and higher pretreatment scar severity were associated with better treatment outcomes. Age, sex, duration of scars, or type of skin did not significantly influence the treatment outcome and adverse effects. CONCLUSION: The study showed that 70% of TCA is a safe and effective treatment option in all types of atrophic acne scars, especially in severe boxcar scars.

Morphological Patterns of Balanoposthitis and their Correlation with Final Etiological Diagnosis.

Background: Balanoposthitis is a common dermatological condition across the globe, but studies describing clinico-morphologic features and their diagnostic correlates are scarce. Objective: To study various morphological patterns of balanoposthitis and their correlation with etiological diagnosis. Materials and Methods: A cross-sectional study was conducted on all patients with balanoposthitis visiting the dermatology out-patient department and sexually transmitted disease (STD) clinic over a period of 8 months. Detailed history, demographic data, and clinical features were recorded. Relevant investigations were performed. Results: A total of 129 patients of balanoposthitis were studied. Common causes were because of candida (33.3%), bacteria (17.1%), irritants (13.3%), herpes (11.4%), drugs (8.6%), and lichen sclerosus (6.7%). Common morphological patterns were erosion/confluent wet erythema with sub-preputial discharge (24.81%), fissure with superficial pustules (15.5%), fissure alone (13.18%), patchy dry erythema (11.63%), and superficial pustules (intact or exfoliated) with or without underlying erythema (10.85%). Fissure and superficial pustules were the most common presentation of candidal balanoposthitis (51.43%), erosions/confluent wet erythema with sub-preputial discharge of bacterial balanitis (55.56%), and patchy dry erythema of irritant balanitis (50%). Limitations: Detailed investigations such as fungal culture, herpes serology, real-time polymerase chain reaction and histopathology could not be performed. Conclusion: Certain morphological patterns of balanoposthitis strongly point toward final diagnosis which can help in quick diagnosis and early treatment in resource poor settings, especially in STDs.

A Study of Cutaneous Adverse Drug Reactions and their Association with Autoimmune Diseases at a Tertiary Centre in South-West Rajasthan, India.

BACKGROUND: Cutaneous adverse drug reactions (CADRs) comprise about 30% of all adverse drug reactions and observed in 2-3% of hospitalized patients by wide variety of offending agents. AIMS: To study the clinical patterns, causative drugs and their association with autoimmune diseases in CADR patients. MATERIALS AND METHODS: A total of 174 CADR patients who presented to the dermatology OPD over a period of 18 months (1 July 2015 to 31 Dec 2016) were considered for the study. Detailed history, clinical examination, hematological, and biochemical investigations were recorded. The venereal disease research laboratory test, HIV (ELISA), and histopathological examination were done wherever indicated. RESULTS: The mean age of the patients with cutaneous drug eruptions was 40.2 years. Most of them (31.0%) were in the age group of 41-50 years. There were 93 (53.4%) males and 81 (46.5%) females with the M:F ratio of 1.5:1. The most common eruption observed was maculopapular rash in 33.3% followed by fixed drug eruption (17.2%) and lichenoid dermatitis' (11.5%). The drugs most commonly responsible for CADRs were antimicrobials (n = 68, 39%) with fixed dose combination of fluoroquinolones with nitroimidazoles (n = 42). We also noticed that a total of 42 patients out of 174 had comorbities in the form of diabetes (n = 27, 15.5%), hypothyroidism (n = 9, 5.1%), rheumatoid arthritis (n = 3, 1.7%), vitiligo (n = 2, 1.1%), and SLE (n = 1, 0.5%). CONCLUSION: Cutaneous ADR patterns and the drugs causing various reactions are changing every year, which may be because of the introduction of newer molecules and changing trends in the use of drugs. In our study, a significant relation of CADRs with autoimmune diseases (P value = 0.004) was also observed.

Dyskeratosis congenita presenting with dysphagia.

Dyskeratosiscongenita (DKC) is a genetically heterogeneous disease of defective telomere maintenance that may demonstrate different patterns of inheritance. It is characterized by thetriad of dystrophy of the nails, leukokeratosis of the oral mucosa, and extensive net-like pigmentation of the skin. We report a case ofDKC who presented with a chief complaint of dysphagia.

Guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis: An Indian perspective.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous adverse drug reactions with a high morbidity and mortality that require immediate medical care. The various immunomodulatory treatments include systemic corticosteroids, cyclosporine, intravenous immunoglobulin, cyclophosphamide, plasmapheresis and tumor necrosis factor-α inhibitors. AIM: The ideal therapy of Stevens-Johnson syndrome/toxic epidermal necrolysis still remains a matter of debate as there are only a limited number of studies of good quality comparing the usefulness of different specific treatments. The aim of this article is to comprehensively review the published medical literature and frame management guidelines suitable in the Indian perspective. METHODS: The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) assigned the task of preparing these guidelines to its special interest group on cutaneous adverse drug reactions. The group performed a comprehensive English language literature search for management options in Stevens-Johnson syndrome/toxic epidermal necrolysis across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for keywords (alone and in combination) and MeSH items such as "guidelines," "Stevens-Johnson syndrome," "toxic epidermal necrolysis," "corticosteroids," "intravenous immunoglobulin," "cyclosporine" and "management." The available evidence was evaluated using the strength of recommendation taxonomy and graded using a three-point scale. A draft of clinical recommendations was developed on the best available evidence which was also scrutinized and critically evaluated by the IADVL Academy of Dermatology. Based on the inputs received, this final consensus statement was prepared. RESULTS: A total of 104 articles (meta-analyses, prospective and retrospective studies, reviews [including chapters in books], previous guidelines [including Indian guidelines of 2006] and case series) were critically evaluated and the evidence thus gathered was used in the preparation of these guidelines. RECOMMENDATIONS: This expert group recommends prompt withdrawal of the culprit drug, meticulous supportive care, and judicious and early (preferably within 72 h) initiation of moderate to high doses of oral or parenteral corticosteroids (prednisolone 1-2 mg/kg/day or equivalent), tapered rapidly within 7-10 days. Cyclosporine (3-5 mg/kg/day) for 10-14 days may also be used either alone, or in combination with corticosteroids. Owing to the systemic nature of the disease, a multidisciplinary approach in the management of these patients is helpful.

A Sporadic Case of Ichthyosis Curth Macklin: Rare Presentation of a Rare Disease.

Ichthyosis hystrix is a rare autosomal dominant genodermatosis, characterized by persistent spiny hyperkeratotic scales which cover a significant part of the skin surface. Based on the pattern of distribution, five clinical variants namely Brocq type, Lambert type, Curth-Macklin type, Rheydt type and Bδfverstedt type have been described. We report the case of an 11-year-old male child with spiny, hyperkeratotic scales all over the body since birth with sparing of scalp and central part of the face. Palmoplantar keratoderma was also present. These clinical features are suggestive of Ichthyosis Curth Macklin, which has been typically described in families. However, family history was negative in our patient. The case is being reported on account of rarity of the disease, that too with a very rare sporadic presentation.

Chromoblastomycosis from a Non-endemic Area and Response to Itraconazole.

Chromoblastomycosis belongs to the heterogeneous group of subcutaneous mycoses. It is caused by various pigmented (dematiaceous) fungi, which gain entry into the skin via traumatic implantation. We would like to share a case report of chromoblastomycosis in a 32-year-old male, who presented to us with 3 years history of slowly progressive, itchy, verrucous, crusted lesions over right forearm and arm. He is being treated with itraconazole 100 mg twice daily. The case is of interest because it has so far not been reported from our region- the northwest arid zone of India. The patient showed favorable response to itraconazole.

Chemical reconstruction of skin scars therapy using 100% trichloroacetic Acid in the treatment of atrophic facial post varicella scars: a pilot study.

CONTEXT: Chickenpox (varicella) is a common viral disease caused by Varicella zoster virus. Facial atrophic scars after varicella infection are not uncommon and pose a cosmetic problem. Like atrophic scars of other aetiologies, they are a difficult condition to treat. There are not enough references in the literature regarding efficient treatment of post varicella scars. High strength Trichloroacetic acid (TCA), which is known to cause dermal collagen remodelling, was used to treat varicella scars in the present study. AIMS: The study was undertaken to assess the efficiency of Chemical Reconstruction of Skin Scars (CROSS) technique using 100% TCA in the treatment of atrophic facial post varicella scars. SETTINGS AND DESIGN: Open label, pilot study. MATERIALS AND METHODS: A total of 16 patients with atrophic facial post varicella scars were treated by focal application of 100% TCA solution by pressing down upon the scar surface by a toothpick (CROSS technique). Total 4 sittings were given at 2 weekly intervals and the results evaluated after 3 months of follow-up. Statistical analysis was carried out using Fischer's exact t-test. RESULTS: All of the 13 patients who completed the study showed good clinical improvement, with 69% patients grading the response as excellent (>75%) improvement, whereas the rest 31% patients reporting good (51-75%) improvement. No significant complications were seen in any patient. CONCLUSIONS: CROSS technique using 100% TCA is a safe, cheap and effective therapy for the treatment of post varicella scars.