Inappropriate Use of Steroids in Superficial Dermatophytosis: An Uncommon Case of Erythroderma.

Erythroderma is a dermatological emergency presenting with generalized erythema and scaling involving <90% of the body surface.1 There are various causes of erythroderma, such as psoriasis, atopic dermatitis, phytophotodermatitis, pityriasis rubra pilaris, pemphigus foliaceus, cutaneous T-cell lymphoma, and drug eruptions.2 However, erythroderma induced by dermatophytosis is encountered rarely. We, here, describe a case of erythroderma developed secondary to extensive dermatophytosis.

Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India).

BACKGROUND: Dermatophytosis management has become an important public health issue, with a large void in research in the area of disease pathophysiology and management. Current treatment recommendations appear to lose their relevance in the current clinical scenario. The objective of the current consensus was to provide an experience-driven approach regarding the diagnosis and management of tinea corporis, cruris and pedis. METHODS: Eleven experts in the field of clinical dermatology and mycology participated in the modified Delphi process consisting of two workshops and five rounds of questionnaires, elaborating definitions, diagnosis and management. Panel members were asked to mark "agree" or "disagree" beside each statement, and provide comments. More than 75% of concordance in response was set to reach the consensus. RESULT: KOH mount microscopy was recommended as a point of care testing. Fungal culture was recommended in chronic, recurrent, relapse, recalcitrant and multisite tinea cases. Topical monotherapy was recommended for naïve tinea cruris and corporis (localised) cases, while a combination of systemic and topical antifungals was recommended for naïve and recalcitrant tinea pedis, extensive lesions of corporis and recalcitrant cases of cruris and corporis. Because of the anti-inflammatory, antibacterial and broad spectrum activity, topical azoles should be preferred. Terbinafine and itraconazole should be the preferred systemic drugs. Minimum duration of treatment should be 2-4 weeks in naïve cases and > 4 weeks in recalcitrant cases. Topical corticosteroid use in the clinical practice of tinea management was strongly discouraged. CONCLUSION: This consensus guideline will help to standardise care, provide guidance on the management, and assist in clinical decision-making for healthcare professionals.

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.

Trichoscopic and Clinico-Morphological Evaluation of Tinea Capitis.

Introduction: Tinea capitis (TC) is a common fungal infection of the scalp, especially in children. Trichoscopy is a noninvasive technique that allows rapid and magnified in vivo observation of the hair with the visualization of morphologic features that are often imperceptible to the naked eye. Aim: This study aimed to evaluate the usefulness of trichoscopy in clinical diagnosis and to study various clinico-morphological patterns of TC. Materials and Methods: This cross-sectional, observational study included 140 clinically diagnosed cases of TC seen during a period of 1 year (April 2021 to March 2022). All patients were evaluated using a dermoscope (DermLite DL4 Multispectral 3 Gen, San Juan Capistrano, CA, USA,10×). Results: The prevalence rate of TC in this study was 2.69 per thousand population. The most common clinical variant was gray patch followed by kerion and black dot, and the most common etiological agent was Trichophyton tonsurans. The characteristic trichoscopic features were as follows: comma hairs (80%), followed by corkscrew hairs (68.6%), bent hairs (54.2%), zigzag hairs (35.7%), and morse code-like hairs (15%). Other findings included scaling (89.2%), followed by black dot (67.1%), broken hairs (42.8%), and crusting and pustules (32.1% each). Comma and corkscrew-shaped hairs were most common in the black dot type, whereas zigzag, bent hairs, and morse code hairs were common in the gray patch type of TC. There was a significant association between trichoscopic findings and type of TC. Conclusion: Trichoscopy can be considered a novel tool for rapid diagnosis and selection of the appropriate therapy and in the monitoring of treatment efficacy in TC.

Prescription Practices Regarding the use of Systemic Drugs in the Management of Patients with Chronic Pruritus amongst Indian Dermatologists - A Questionnaire Based Survey.

Background: Chronic pruritus poses a significant challenge to treating physicians due to multitude of underlying causes and varying treatment strategies. Several topical, systemic, and physical modalities have been tried with variable success. Prescription practices in chronic pruritus are influenced by differential knowledge and experience of physicians, patient-related factors, and resource availability. Aim: The purpose of this survey was to observe the current pattern of practice in Indian dermatologists in the management of chronic pruritus and to identify practice gaps particularly regarding the use of various systemic agents as antipruritics. Materials and Methods: A previously validated questionnaire was sent to consultant dermatologists across India between January 2020 and July 2020. The questionnaire was comprised of six questions (multiple-choice questions as well as open-ended questions) regarding the use of antidepressants, cyclic gamma-aminobutyric acid (GABA) analogues, opioid antagonists, antihistamines, and alternate therapies in the management of chronic pruritus. Results: A total of 700 dermatologists completed the questionnaire (response rate 70%). Overall, antihistamines were the most common drug prescribed in chronic pruritus (more than 95% respondents). Other systemic agents such as opioid antagonists, gabapentinoids, and antidepressants were prescribed by 22.42%, 71.85%, and 75.29% respondents, respectively, in chronic pruritus as either monotherapy or in combination with antihistamines in specific types of itches. Among antidepressants, tricyclic antidepressants (TCAs) (69.29%) were prescribed most often, followed by selective serotonin reuptake inhibitors (SSRIs) (32.29%) and serotonin and norepinephrine reuptake inhibitors (SNRIs) (9.14%). Other treatment options such as omalizumab, thalidomide, ondansetron, ursodeoxycholic acid (UDCA), and rifampicin were used by 10% respondents to alleviate pruritus in special situations. Conclusion: This survey revealed the redundant practice of prescribing antihistamines in chronic pruritus irrespective of etiology among Indian dermatologists. It also revealed a differential approach regarding use of systemic agents such as gabapentinoids, opioid antagonists, and antidepressants, in academic and non-academic institutions. The survey emphasized a barrier in writing prescription of systemic agents such as opioid antagonist and SNRIs due to lack of knowledge and experience, fear of side effects, and inadequate available evidence.

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.

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.

Cyclosporine in Cholinergic Itch.

Cholinergic itch is part of symptom complex that also includes cholinergic erythema and cholinergic urticaria. It mostly occurs during the winters among young adults. It is characterized by onset of severe itching or burning sensation all over body, mostly, on exposure to sunlight, warm atmosphere and in some cases after hot and spicy food intake. In most of the cases, it is poorly responsive to antihistamine therapy. Materials and methods: This was a prospective, open labeled, clinical study done in patients of cholinergic itch, refractory to both sedating and non sedating anti-histamine drugs, who attended dermatology clinic of our tertiary care center from November, 2020 to February, 2021. Oral cyclosporine was given as treatment. Numerical rating scale (NRS) was used to record the treatment response. Results: Twenty patients with cholinergic itch meeting inclusion criteria were included in the study. Mean age of disease onset was 19.5 years. Average duration of each episode was 4.4-8 minutes. More than one site was involved in all patients with trunk being the commonest (100%). There was significant reduction in the number of episodes and cholinergic itch severity (mean NRS=7.8 to 0.3 at the end of second week after initiating cyclosporine therapy). P value of the study was <0.0001. Statistics: Mean and standard deviation were used as measure of central tendency. Paired t test was applied to analyze the data obtained. Conclusion: Oral cyclosporine effectively controlled cholinergic itch in all included patients. Drug was well tolerated by the patients.

Knowledge, Attitude and Practice for Pruritus Management in Physicians and Patients with Diabetes.

Pruritus is a common dermatological condition observed in patients with diabetes, making it a dermatometabolic condition. Being multiaethiological, pruritis is caused by autoimmune, genetic, infectious and various systemic diseases. The present survey aimed to understand the knowledge, attitude and practice toward pruritus among Indian physicians and patients with diabetes presenting with pruritus. A telephonic, cross-sectional, qualitative survey was conducted among physicians and patients across five cities in India from July-August 2020. An open-ended discussion guide was used for the interview; the data were analyzed to check for common themes and trends. A majority of the consulting physicians (CPs) believed that uncontrolled diabetes is the main causal factor for pruritus in patients with diabetes and reported that currently there are no standard tests or treatment guidelines for its management. CPs emphasized proper monitoring and counseling to overcome current challenges. Patients reported a negative impact of pruritus on their daily activities and quality of life. The survey concluded that poor management of diabetes is one of the main causal factors for patients with diabetes presenting with pruritus in India. CPs emphasized controlling diabetes along with symptomatic treatment. For patients, pruritus has multifaceted effects on their health, overall well-being, and quality of life.

Cyclosporine in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Experience from a Tertiary Care Centre of South Rajasthan.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous drug reactions with a high morbidity and mortality that require immediate medical care. Several immunomodulatory drugs are used for the treatment but evidence of their efficacy is limited. Cyclosporine has recently been found to have a promising role in SJS/TEN owing to its potent antiapoptotic activity. AIMS: This open label prospective study was conducted to determine the efficacy, safety, and tolerability of cyclosporine in patients with SJS/TEN. METHODS: This study was conducted at a tertiary care teaching hospital of South Rajasthan during a period of 4 years (August 2015 to July 2019). Data regarding clinical profile, causative drug(s), disease severity, associated comorbidities, treatment received, and outcome were recorded in a predesigned proforma. SCORTEN prognostic score was calculated for each patient at the time of admission. Cyclosporine was administered in a dose of 5 mg/kg body weight in two divided dosage until reepithelization. RESULTS: Out of 16 patients 10 were males and 6 were females. Mean age of patients was 30.62 ± 16.98 years (range: 7-63). Most of the patients, i.e., 8 out of 16 had TEN, 5 patients had SJS, and 3 patients had SJS/TEN overlap. Mean ± SD delay between onset and admission was 3.812 ± 1.377 days (range: 2-7). Among the suspected drugs, antiepileptics (43.7%) formed the major group. Mean duration of reepithelization was 10.5 ± 3.46 days (range: 7-15). Based on the SCORTEN, the expected mortality was 2.55 with mean predicted mortality rate of 16.43% with SD of 19.3. LIMITATIONS: 1) Sample size was small. 2) Placebo control trial could not be done due to the severity of the disease. CONCLUSION: We recommend cyclosporine (5 mg/kg/day) as the first line-specific immunomodulatory agent in SJS/TEN on account of its efficacy, safety, rapid reepithelization, decrease hospital stay, and reduced morbidity and mortality.

A Clinico-Epidemiological Study of Cutaneous Leishmaniasis in a Non-Endemic Region of South Rajasthan.

INTRODUCTION: Cutaneous leishmaniasis (CL) is a vector-borne protozoal infection of the skin with variable clinical manifestations. In Rajasthan, western Thar desert is endemic for this disease. AIM: The present study was aimed to describe clinico-epidemiological features of cutaneous leishmaniasis cases from a non-endemic area of South Rajasthan. MATERIALS AND METHODS: A hospital-based prospective study was carried out during a period of 3 years (2017-2019). Data regarding clinical profile and treatment outcome were recorded in a predesigned proforma for analysis. Diagnosis of CL was made clinically and confirmed by demonstration of amastigotes in microscopic examination of Giemsa stained tissue smear of lesions. RESULTS: Out of 24 patients, 16 (67%) were females and 8 (33%) were males. The age ranged from 3 months to 68 years (median-25). Face (67%) and extremities (29%) were the common sites affected. The most common morphological form was crusted plaques (54%) followed by nodular lesions (38%). Slit skin smear for Leishmania donovani bodies was positive in all patients (100%). CONCLUSION: This study highlights a focus of CL in non-endemic areas of South Rajasthan. Of late leishmaniasis is breaking out of its classical boundaries and is increasingly being reported from new geographic locations with a possibility of a novel parasite variant. Therefore, a high clinical suspicion of CL should be kept in non-endemic area.

Sonographic Evaluation of Subclinical Enthesopathy in Patients of Chronic Plaque Psoriasis.

BACKGROUND: Psoriasis is associated with spondyloarthropathy in 10%-30% of cases. Enthesitis is major feature of psoriatic arthritis. Ultrasonography can detect subclinical entheseal abnormalities in psoriasis patients. OBJECTIVES: To determine the prevalence of subclinical enthesopathy in psoriasis vulgaris using ultrasonography and evaluating its correlation with severity and duration of psoriasis. MATERIALS AND METHODS: This study included 50 patients of psoriasis vulgaris and 50 healthy controls. Sonographic evaluation of six sites bilaterally (proximal plantar fascia, distal Achilles tendon, distal and proximal patellar ligaments, distal quadriceps, and brachial triceps tendons) were done in each subject. All Ultrasonographic findings were identified according to MASEI (Madrid sonography enthesitis index). Enthesopathy scores of patients and controls were compared and receiver operating characteristic curve was used to determine cut off value of MASEI, above which ultrasound enthesitis of clinical significance could be diagnosed. RESULTS: 31 (62%) psoriasis patients had subclinical enthesopathy of clinical significance as compared to only 5 (10%) of controls. Mean MASEI score between psoriasis cases and control was statistically different, 12.72 ± 7.55 (Mean ± SD) and (5.14 ± 4.69), respectively (P value 0.000001).The receiver operating characteristic curve established an ultrasound score of >11 as the best cut-off to differentiate between subject with enthesopathy of clinical significance from those with enthesopathy of unknown significance. No statistically significant correlation was found between the degree of enthesopathy (MASEI score) and duration and severity of the psoriasis. CONCLUSION: Ultrasonography can effectively screen subclinical entheseal abnormalities in psoriasis patients.

Current treatment strategies in refractory chronic pruritus.

Chronic pruritus is a highly prevalent, debilitating disease, which is often refractory to conventional therapies. A step-wise, guideline-driven approach should be adopted in the management of these patients. Emollients as well as topical corticosteroids if appropriate should be initiated whilst looking for the cause underlying the pruritus. If these measures fail, and the origin of the pruritus remains unknown, cannot be treated or does not respond to therapy, systemic therapies as for example gabapentinoids, antidepressants, mu-opioid-receptor antagonists or, in case of inflammatory conditions, immunosuppressive drugs should be recommended. Novel agents, especially systemic monoclonal antibodies, neurokinin-1 receptor antagonists and opioid receptor modulators, are promising in providing relief in refractory cases.

Clinical Profile and Comparison of Causality Assessment Tools in Cutaneous Adverse Drug Reactions.

BACKGROUND: Cutaneous adverse drug reactions (CADRs) are probably the most frequent of all manifestations of drug sensitivity. As a considerable number of new drugs are periodically introduced into the market, the incidence of CADR is likely to increase. The pattern of CADR and the causative drugs is likely to change accordingly. There is no uniformly accepted and reliable method of objectively assessing the causal link between drug and adverse reaction. AIM: To study the clinical patterns and causative drugs and compare causality assessment [World Health Organization (WHO) and Naranjo algorithm] of CADR among patients attending the dermatology department. MATERIALS AND METHODS: This is a cross-sectional hospital-based study in which all patients with suspected CADR attending the dermatology department of a tertiary care center over a 9-month period were evaluated using the causality assessment criteria recommended by the WHO-Uppsala Monitoring Centre (UMC) and Naranjo scale. The severity of the reaction was assessed using Adverse Drug Reaction Severity Assessment Scale (modified Hartwig and Siegel scale). RESULTS: A total of 200 consecutive patients with CADR were evaluated. The causality assessment for a drug as per WHO scale yielded 63 (31.5%) cases as certain, 12 (6%) as probable, and 125 (62.5%) as possible, whereas Naranjo scale showed 26 (13%) cases to be definite, 138 (69%) as probable, and 36 (18%) as possible. There was poor agreement between the two scales. Fixed drug eruption was the most common pattern of CADR (82.41%). The average number of drugs received by patients was 2.09. The most common suspected drug group was antimicrobials (n = 170; 40.5%), followed by nonsteroidal anti-inflammatory drugs (n = 148; 35.3%) and antiretroviral drugs (n = 41; 9.7%). Fixed drug eruption was most commonly caused by paracetamol. Antiepileptics and antimicrobials were the most common suspects among severe cutaneous adverse reactions. LIMITATIONS: Multiple concomitant drug usage by patients and inability to provoke all patients/measure drug levels in blood resulted in higher number of drugs with causal association as probable/possible. CONCLUSION: WHO-UMC scale was found to be easier to apply and evaluate, with greater practical utility. Poor agreement between the two commonly used scales emphasizes the need for a consistent and uniform causality assessment tool.

Chronic Arsenicosis: Cases from a Nonendemic Area of South Rajasthan.

Two adult patients from a village of district Bhilwara, Rajasthan, consulted Skin Department of R. N. T. Medical College and Hospital, Udaipur, with complaints of thickening of the palms and soles and pigmentation of skin with a nonhealing ulcer on the palm. They also had complaints of loss of appetite, abdominal pain, nausea, vomiting, and loose motion. On examination, there were multiple 2-3 mm, keratotic papules on the palms, and soles on the background of diffuse keratoderma. Two irregular nonhealing ulcers were present on the hands which on excisional biopsy revealed squamous cell carcinoma. A generalized mottled pigmentation was present over the trunk and proximal parts of extremities. The clinical presentation was suggestive of arsenicosis. There was history of similar ailment in some of the fellow villagers as well. With the help of health authorities, a survey was conducted in the village and it was found that eight more villagers were suffering from similar kind of illness. The common source of arsenic was explored and found to be increased in drinking water that was taken out through hand pump. The level of arsenic in drinking water was significantly above the WHO safe limit for arsenic.

A Randomized double Blind Controlled Study Comparing the Efficacy of Intralesional MMR Vaccine with Normal Saline in the Treatment of Cutaneous Warts.

BACKGROUND: Recently, with better understanding of the immunology of warts, immunotherapeutic approaches have emerged as an effective treatment option for the management of cutaneous warts. Intralesional immunotherapy with MMR vaccine is one such modality but there are still lack of enough placebo-controlled studies. AIM: To evaluate the efficacy of intralesional MMR in patients of extragenital warts in a double-blinded manner using normal saline as control. PATIENTS AND METHODS: One hundred patients of extragenital cutaneous warts were randomly allocated into two groups, the interventional (MMR) group and control (normal saline) group. MMR vaccine was injected intralesionally in the patients belonging to interventional group, a similar volume of normal saline (NS) was injected in the control group. The outcome in terms of treatment response, adverse effects, and recurrences were evaluated and compared. RESULTS: Eighteen of thirty (60%) patients in the interventional group achieved complete response as against 7 (23.3%) in the control group (P = 0.01). Distant warts cleared in 69.5% patients in the interventional groupcompared to none in the control group. Adverse effects seen in both groups were injection site pain and mild erythema. A total of 57.1% patients showed recurrences in the control group compared to 16.6% in the interventional group. CONCLUSION: Intralesional MMR vaccine is an effective treatment option in patients with multiple extragenital warts. It is suggested that it should be used as first-line therapy for multiple warts and a second-line therapy for warts recalcitrant to standard therapies.

Diffuse Cutaneous Leishmaniasis in an Immunocompromised Patient Resembling Histoid Hansen's Disease.

Cutaneous leishmaniasis is caused by protozoan parasites of the genus Leishmania. Atypical presentation and widespread progression of the lesions may be seen in patients with HIV disease and diffuse cutaneous leishmaniasis and HIV co-infection is emerging as a serious new threat. We report a case of diffuse cutaneous leishmaniasis in a HIV- infected patient resembling Histoid Hansen.