Clinical Use of Super-Bioavailable Itraconazole for the Management of Dermatophytosis: Consensus Statement by Dermatologists from India via the Modified Delphi Technique.

Super-bioavailable itraconazole (SB ITZ) overcomes the limitations of conventional itraconazole (CITZ) such as interindividual variability and reduced bioavailability. It has been approved for systemic mycoses in Australia and Europe as 50 mg and the USA as 65 mg and in India as 50 mg, 65 mg, 100 mg, and 130 mg. However, data on the ideal dose and duration of SB ITZ treatment in managing dermatophytosis are insufficient. This consensus discusses the suitability, dosage, duration of treatment, and relevance of using SB ITZ in managing dermatophytosis in different clinical scenarios. Sixteen dermatologists (>15 years of experience in the field and ≥2 years clinical experience with SB ITZ), formed the expert panel. A modified Delphi technique was employed, and a consensus was reached if the concordance in response was >75%. A total of 26 consensus statements were developed. The preferred dose of SB ITZ is 130 mg once daily and if not tolerated, 65 mg twice daily. The preferred duration for treating naïve dermatophytosis is 4-6 weeks and that for recalcitrant dermatophytosis is 6-8 weeks. Moreover, cure rates for dermatophytosis are a little better with SB ITZ than with CITZ with a similar safety profile as of CITZ. Better patient compliance and efficacy are associated with SB ITZ than with CITZ, even in patients with comorbidities and special needs such as patients with diabetes, extensive lesions, corticosteroid abuse, adolescents, and those on multiple drugs. Expert clinicians reported that the overall clinical experience with SB ITZ was better than that with CITZ.

Frequency of Locator Legacy Insert Changes With Implant Overdentures in a UK Population.

PURPOSE: To determine the frequency of insert changes for combined maxillary and mandibular implant overdentures (IOD) using the Locator Legacy system. A secondary objective was to assess the survival of dental implants with IODs. MATERIALS AND METHODS: This retrospective audit reviewed clinical records with up to 12 years follow up from 785 patients who received IODs using the Locator system at a dental hospital. From these, 151 had a combined maxillary opposed by a mandibular IOD and from this, 37 had data retrieved using a minimum data set. The frequency of insert change was recorded and descriptive analysis was provided by means and standard deviations for continuous variables. Frequencies of categorical values were reported as percentages. RESULTS: 222 implants were placed on 21 men, 16 women with a mean age 67.5 years (SD 8.8). All patients were reviewed at least once. Maxillary and mandibular IODs experienced 1.9 (SD 2.0) and 1.2 (SD 1.2) mean insert changes per patient, respectively. The mean time (SD) between initial and first insert change for maxillary and mandibular IODs was 3.4 months (SD 3.2) and 6.4 months (SD 7.2) and between the first and second insert change was 9.9 months (SD 9.0) and 10.0 months (SD 8.3), respectively. Implant failure was 21.6% and 2.7% in the maxilla and mandible respectively. CONCLUSIONS: Clinicians should anticipate the first insert change around 3 months for maxillary IOD and 6 months for mandibular IOD. Subsequently, the second insert change to be around 10 months for both maxillary and mandibular IODs.

Therapeutic Inertia in the Management of Psoriasis: A Quantitative Survey Among Indian Dermatologists and Patients.

Purpose: The primary objective of the study was to understand the therapeutic inertia in treatment and management of plaque psoriasis among dermatologists, along with determining the preferred treatment choices for management of plaque psoriasis; it also included the resulting treatment satisfaction among patients. The secondary objective was to identify the gaps in terms of knowledge and attitude among dermatologists and the expectations of patients. Patients and Methods: A multicentre, cross-sectional quantitative survey was conducted among dermatologists and patients with moderate to severe plaque psoriasis across India. The interviews were conducted either face to face or via telephone between September and November 2020, using structured and validated questionnaires based on specific themes. The data obtained were statistically analysed, wherever applicable. Results: Overall, 207 adult patients with moderate-to-severe plaque psoriasis and 303 dermatologists were interviewed. Post experiencing symptoms, 44% of the patients visited general physicians for treatment and there was an average 7.8-month delay by the patients to consult a dermatologist. Approximately one-fourth of patients used home remedies before seeking medical help. One-third of dermatologists used the Psoriasis Area and Severity Index (PASI) for assessing the disease severity. Majority of dermatologists preferred combination therapy for their patients. The lack of quick resolution and side effects were the major reasons for changing the treatment. Overall, only 35% of the patients complied to current treatment. Satisfaction with existing forms of therapies was highest for mild plaque psoriasis (62%) as confirmed by dermatologists, while 52% of the overall patients were satisfied with their therapy. Majority of the patients (64%) affirmed living with plaque psoriasis impacted their lives. Conclusion: This first-of-its-kind survey in India highlighted the gaps in terms of the disease journey between dermatologists and patients. The survey emphasises the need for shared decision-making and may benefit dermatologists in suggestive modifications of the treatment algorithm and disease management in clinical settings.

The Use of Apremilast in Psoriasis: An Indian Perspective on Real-World Scenarios.

Apremilast, an oral phosphodiesterase-4 inhibitor, is approved for use in the management of psoriasis and psoriatic arthritis. Although its efficacy and safety have been well established in clinical studies, in real-world settings, different practice scenarios have been reported. This review paper serves to evaluate clinical real-world scenarios and aspects of treatment for which the information in the literature was considered to be lacking or controversial. Following a literature review, a panel of five dermatologists with expertise in psoriasis considered five scenarios; namely, the positioning of apremilast in psoriasis, its use in difficult-to-treat areas, special conditions and populations, safety, dose titration and dose in maintenance therapy. These were then assessed with psoriasis experts in India using a web-based questionnaire. A total of 28 questions were discussed regarding these scenarios. According to the responses, apremilast is effective in stable mild to moderate psoriasis as monotherapy and in severe psoriasis in combination. Also, a positive response was received with regard to its effectiveness in difficult locations such as the scalp, palms and soles. To reduce adverse effects, prolonged titration therapy over 4 weeks is required and lower doses can be prescribed to maintain remission. Apremilast therapy should be continued for a minimum of 8 weeks once initiated to achieve the desired results, and the total duration of therapy should be about 24 weeks for better efficacy. It is also effective in many other cases, such as obese patients, patients with hepatitis B or C and HIV, or patients on polypharmacy. It was also reported that apremilast requires less prescreening and monitoring than other conventional and biologic systemic therapies. Overall, apremilast is an attractive option for the individualized treatment of psoriasis owing to its favorable safety profile, its ease of oral administration without the need for screening or ongoing laboratory monitoring, and its positive impact on symptoms and lesions in difficult-to-treat areas.

A systematic review and meta analysis of the longevity of anterior and posterior all-ceramic crowns.

BACKGROUND: Clinical experience suggests that there is a difference in survival between anterior and posterior all ceramic restorations. OBJECTIVES: This systematic review compared the difference in survival for full coverage all-ceramic materials used in adults to restore anterior or posterior vital teeth, not involved with fixed dental prostheses, but opposed by teeth. DATA AND SOURCES: Searches using Medline, Embase, and the Cochrane Library, including hand searches, with the inclusion criteria containing all-ceramic full coverage crowns in human adults over 17 years of age, prospective and retrospective studies, opposed by teeth, periodontal pocketing ≤5mm, but not involving implant supported crowns or non-vital teeth. All papers were published between 1980 and March 2014 and available in English. From the selected studies a meta analysis was undertaken. The chi square test, I2, Begg's and Egger's test were analysed and the publication bias was assessed using a Funnel plot. The, Kappa scores were 0.63, 0.88, and 0.81 at each selection stage. STUDY SELECTIONS: Pooled data produced 1112 anterior crowns with 73 failures (6.5%) and 1821 posterior crowns with 166 failures (9.1%) with a follow up time from 36 to 223 months. Relative risk meta-analysis of the 14 selected papers demonstrated that anterior all-ceramic crowns were 50% less likely to fail than posterior all-ceramic crowns (p=0.001). CONCLUSION: These results indicate that there were differences in failure between anterior and posterior all ceramic crowns but the difference was only 3%. Although this has clinical relevance and some caution is needed when prescribing all ceramic posterior crowns the difference was relatively small. CLINICAL SIGNIFICANCE: The clinically relevant results of this review, based on currently available data, demonstrate a need for some caution when considering posterior all-ceramic crowns. Lithium disilicate restorations were observed to have higher failures on anterior restorations and more research is needed to investigate why.

An in vivo investigation of associations between saliva properties, caries prevalence and potential lesion activity in an adult UK population.

OBJECTIVE: To investigate associations between prevalence and activity of intra-oral incipient, carious lesions and salivary properties tested using the Saliva Check kit (GC Corp., Belgium). METHODS: With ethical approval, 58 subjects with >16 teeth underwent clinical/radiographic examination. Conventional decayed, missing, filled teeth/decayed, missing, filled surfaces (DMFT/DMFS) indices and a more recently developed visual index described by International Caries Detection and Assessment System (ICDAS) were used to ascertain caries prevalence. Potential lesion activity was scored using an Ekstrand visual index. Saliva properties tested included hydration, resting pH, stimulated flow and buffering capacity. Spearman's rank correlation was used to analyse data. RESULTS: No saliva parameters correlated significantly with DMFT/DMFS caries prevalence scores (D3 threshold). The resting pH correlated negatively and significantly with the total number of lesions (r=-0.267, p=0.043), with ICDAS scores >1 (r=-0.333, p=0.011) and with mild lesions (r=-0.263, p=0.046). A negative correlation was found between saliva buffering capacity and the potential activity of moderate lesions (ICDAS 3 and 4; r=-0.227, p=0.035). CONCLUSIONS: There appeared to be a correlation between the resting pH of saliva and the prevalence of early lesions as well as the saliva buffering capacity and the potential lesion activity of moderate lesions. A difference was shown between lesion prevalence calculated using traditional DMFT(S) D3 versus the ICDAS D1 thresholding.

Clothes-on PUVA in psoriasis: single blind randomized comparative trial on 21 patients.

BACKGROUND: PUVASOL therapy has an inherent drawback of patient compliance in that Indian female patients with psoriasis lesions on covered parts of the body are reluctant to expose themselves. In this study we tried to evaluate a new method of administering PUVA therapy wearing a fabric. AIM: To compare the efficacy and safety of PUVA administration with and without wearing clothes in psoriasis. METHOD: We first found the UV transmissibility of plain woven, lightweight cream colored cotton fabric with 30 x 30 threads per square cm. area and calculated its sun protection factor (SPF). A single blind, randomized, comparative, clinical trial was then conducted on 21 patients with psoriasis vulgaris who were treated with bath PUVA. The study group received ultraviolet light while wearing a gown made up of the above cotton fabric and the control group received ultraviolet light without wearing the gown. The study group was given an UV dose higher in proportion to the SPF of the worn fabric so that blockage caused by cloth could be neutralized. The cloth-uncovered areas were covered with a sunscreen. UVA from artificial light source was used for better patient monitoring. RESULTS: After 12 PUVA treatments both the treatments were found to be equally effective, and there were no differences in the side effects. CONCLUSION: Thus we conclude that PUVA can be given wearing a fabric provided the UV dosage is increased proportional to the SPF of the fabric. The same fabric may be used for PUVASOL therapy.