Effectiveness, safety, and tolerability of bilastine 20 mg vs levocetirizine 5 mg for the treatment of chronic spontaneous urticaria: A double-blind, parallel group, randomized controlled trial.

Chronic spontaneous urticaria (CSU) is a debilitating condition, adversely affecting the patient's quality of life. Bilastine is a recently introduced, non-sedative H1-antihistamine for its treatment. We wanted to compare the effectiveness, safety, and tolerability of bilastine 20 mg vs levocetirizine 5 mg in moderate-to-severe CSU. We conducted a double-blind, randomized controlled trial with two groups: bilastine 20 mg (n = 31) and levocetirizine 5 mg (n = 27), once daily for 42 days. We included patients (18-65 years), with moderate-to-severe CSU. UAS7, VAS, and DLQI were used to assess severity of urticaria, global urticaria-induced discomfort and quality of life, respectively. DLQI was assessed at baseline (D0) and end-of-treatment (D42), while UAS7 and VAS were noted at baseline and all follow-up visits. Assessment of UAS7 alteration was our primary objective, while changes in DLQI and VAS were the secondary outcomes. Safety was assessed by recording drug-related adverse events, biochemical investigations, and electrocardiogram, along with tolerability and compliance. Both drugs significantly improved UAS7, DLQI, and VAS at end-of-treatment (D42) compared with baseline (intra-group). At the end-of-treatment, all parameters showed greater improvement with bilastine, but only UAS7 reduction was significant (bilastine > levocetirizine, P = .03). In both the groups, UAS7 and VAS improved significantly D14 onwards, and was maintained throughout the study. Sedation was significantly less with bilastine (P = .04), while neither drug showed any serious adverse-effect. Tolerability of both drugs was similar. Therefore, bilastine was found to be a more effective and less-sedative novel therapy for CSU compared to levocetirizine, with similar effect on quality of life.

Multiple keratotic papules on palm.

Porokeratotic eccrine ostial and dermal duct nevus (PEODDN) is a rare nonhereditary malformation of the eccrine duct. A relationship with linear porokeratosis is not yet established; some consider it as a rare variant of porokeratosis involving the acrosyringium, whereas others consider it a separate entity based on distinctive clinical features and histologic accentuation within ostial structures. A 7-year-old girl presented with multiple asymptomatic keratotic papules over her right palm, present since the age of 6 months. These papules were arranged in a linear distribution over the palm and middle finger of the right hand. Most of the papules were discrete. However, lesions on the middle finger coalesced to form a plaque. Histology revealed a keratin filled deep invagination of the epidermis, notable for a column of parakeratosis ("cornoid lamella"). The dermis was notable for dilated eccrine ducts and absent inflammation. Considering the clinical and histological evidence, a diagnosis of PEODDN was made. Its clinical resemblance to linear lichen planus and linear porokeratosis is discussed. Also, we provide a brief review of this rare condition.

Sex Hormones, Metabolic Status, and Obesity in Female Patients with Acne Vulgaris Along with Clinical Correlation: An Observational Cross-Sectional Study.

BACKGROUND: Acne vulgaris is a common dermatological disorder. Several hormones are suspected to play a role in its etiopathogenesis. AIMS AND OBJECTIVES: The aim of this study was to analyze the role of sex-hormones, metabolic status, and obesity in acne vulgaris and correlate with its severity and symptom load. MATERIALS AND METHODS: This cross-sectional observational study included 89 female patients with acne vulgaris and certain phenotypic markers such as prepubertal onset, late-onset, persistent course, hirsutism, acanthosis nigricans, acrochordons, premenstrual flare, and diminished response to isotretinoin; suggestive of an underlying hormonal pathology. All patients were subjected to physical examination to rule out obesity and metabolic syndrome along with serum biochemistry to detect sex hormones (testosterone, progesterone, estrogen), serum insulin and insulin resistance (HOMA-IR) and lipid profile. RESULTS: Among 89 patients (mean age 21.3 ± 5.3 years), 34.8% presented with late-onset/persistent/pre-pubertal acne, 33.7% presented with premenstrual flare and 28.2% presented with hirsutism. Hormonal analysis revealed elevated testosterone and progesterone with low estrogen across all categories of patients. Testosterone was significantly elevated even in mild acne. Serum lipid profile was altered significantly only in hirsute females. In total, 36% and 20.2% patients presented with metabolic syndrome and obesity, respectively; however, neither was associated with severity of acne. CONCLUSION: Sex-hormones, serum lipids, metabolic status, and body mass index are altered in acne vulgaris. All acne patients with endocrine markers should be evaluated for sex-hormones irrespective of severity and symptom load, whereas hirsutism may be regarded as clinical marker of lipid abnormalities. Metabolic syndrome and obesity do not seem to be directly correlated with acne severity. Thus, anti-androgens may be considered as adjuvant therapy in these patients, not responding to conventional therapy.

Interdepartmental Dermatology: Characteristics and Impact of Dermatology Inpatient Referrals at a Teaching Hospital in Eastern India.

BACKGROUND: Dermatology is primarily considered to be an outpatient-centered specialty. However, several inpatient admissions to other specialties require dermatologic consultation for optimum management. AIMS: To analyze the causes of inpatient dermatology referrals, departments sending referrals, and impact of dermatology consultation on patient management. MATERIALS AND METHODS: We conducted a cross-sectional study by analyzing the records of 486 patient referrals over a 4-year period. The demographic details, specialties requesting consultation, cause of referral, and dermatological advice have been recorded and analyzed. RESULTS: Dermatology consultation changed the dermatologic diagnosis and treatment of almost two-thirds of patients. General medicine requested the maximum number of referrals, "skin rash" being the most common cause for referral. Accurate diagnosis on referrals was provided by only 30.2% of nondermatologists. Common dermatological disorders were often misdiagnosed by these physicians, and dermatology referrals had significant impact on the diagnosis and subsequent management of these patients. CONCLUSION: While dermatologic referral leads to improved patient care, there is a need for better training of nondermatologists enabling them to recognize and treat common dermatoses.

A Clinicopathological Study of Pemphigus in Eastern India with Special Reference to Direct Immunofluorescence.

BACKGROUND: Pemphigus is a group of chronic autoimmune vesico-bullous disorders in which the epidermis and the basement membrane zone are the focus of attack resulting in cutaneous and mucosal blister formation. Direct immunofluorescence (DIF) test is a very sensitive test for the diagnosis. AIM: To study the clinico histopathological patterns of pemphigus in eastern India. The study also aims to correlate DIF with clinical and histologic findings as well as severity of skin involvement [scoring systems]. MATERIALS AND METHODS: Total 41 patients were studied over a period of 1 year in the Post-graduate centre of Dermatology in Eastern India. DIF, histopathology and clinical data were correlated. RESULTS: In our study Pemphigus vulgaris (PV) was the predominant type with 32 cases followed by 8 cases of pemphigus foliaceus (PF) and a single case of IgA pemphigus. Mean age at presentation was late middle age. Majority of the patients, 26 (63.41%) initially had cutaneous involvement followed by mucosal involvement. In this study group 36 (87.80%) patients showed acantholytic cells on histopathological examination. Most patients of PV showed suprabasal blister 20 (62.50%) followed by intraspinous 5 (15.62%) and subcorneal 5 (15.62%) blister. In majority 28 (87.50%) of the PV patients IgG and C3 antibodies were deposited throughout the epidermis. The strength of antibody positivity was strong in most of the patients (71.87%). In cases of PF mostly IgG 6 (75%) antibodies were deposited in the upper epidermis. DIF intensity had poor correlation with disease activity/severity except in PF. CONCLUSION: Almost 85.36% cases of pemphigus were diagnosed clinicopathologically. But 6 cases couldn't be diagnosed accurately on clinicopathological basis and in them DIF was confirmatory. Two cases of pure mucosal PV and 1 case of IgA pemphigus was confirmed by DIF. Two cases of bullous pemphigoid clinico-histologically mimicking PV were also excluded by DIF. So it appears from our study that DIF is confirmatory for diagnosis of pemphigus in all cases.

Angiokeratoma circumscriptum neviforme: An entity, few and far between.

Angiokeratomas are a group of vascular ectasias that involve the papillary dermis and may produce papillomatosis, acanthosis and hyperkeratosis of the epidermis. Angiokeratoma circumscriptum is the least common variant among many types. Angiokeratoma circumscriptum neviforme is a still rarer variety of angiokeratoma, which is classically seen at birth. We report here a case of congenital, linear, unilateral, verrucous plaques on the leg of a young girl, diagnosed as angiokeratoma circumscriptum neviforme (ACN).

Cutaneous adverse drug reaction profile in a tertiary care out patient setting in eastern India.

BACKGROUND: Cutaneous adverse drug reactions (CADR) are the most frequent of all manifestations of drug sensitivity and manifest with varied and diverse morphology. AIMS: To study the prevalence and clinical spectrum of CADR among patients attending outpatient department (OPD) in a tertiary care hospital. MATERIALS AND METHODS: An observational study was undertaken over a 1-year period in dermatology OPD of a tertiary care teaching hospital in Eastern India. Patients presenting with suspected drug-related cutaneous lesions were included if drug identity could be ascertained. Clinical profiling was done. Drug history was recorded in a format specified in Indian National Pharmacovigilance Programme and causality assessment carried out as per World Health Organization-Uppsala Monitoring Centre (WHO-UMC) criteria. RESULTS: Commonest CADR in our study was morbilliform eruption (30.18%), followed by fixed drug eruption (24.52%), Stevens-Johnson syndrome (SJS)-Toxic epidermal necrolysis (TEN) and overlap of two (24.50%), exfoliative dermatitis (7.54%), urticaria (5.6%), phototoxic drug reaction (3.8%), pityriasis rosea-like eruptions (1.89%), and severe mucositis (1.80%). Drugs implicated were sulfonamides (17%), fixed-dose combinations of fluoroquinolones with nitroimidazoles (11.30%), analgesics (11.30%), antiepileptics (11.30%), beta-lactam antibiotics (9.40%), fluoroquinolones alone (7.50%), allopurinol (7.50%), and azithromycin (5.70%). Reaction latency varied from 1 to 43 days. Causality assessment was certain and probable for 18.9% and 41.5% of the reactions, respectively, and reactions were serious in 33.96% (95% confidence interval 21.21-46.71%). CONCLUSIONS: Cutaneous adverse drug reaction profile in this study is similar in many ways to studies conducted earlier in India. Incidence of life-threatening reactions like SJS-TEN was higher compared with studies conducted abroad. Reaction time and lesion patterns are helpful in identifying an offending drug in the setting of multiple drug therapy.