Bleach suit for atopic dermatitis.

Bleach baths are an important adjunct in the management of atopic dermatitis. However, many homes do not have bath tubs. We tried to overcome this by soaking a cotton pajama suit or Indian kurta pajama in dilute bleach solution and then having the child wear it for ten minutes. This is done two to three times a week, as in standard bleach tub baths. We have tried this technique in eleven patients with satisfactory outcomes and no adverse effects.

The influence of superficial dermatophytoses epidemic in India on patients' quality of life.

INTRODUCTION: Superficial dermatophytoses constitute a common and growing problem in India. However, the associated impact on the affected individuals' quality of life (QoL) has rarely been investigated. AIM: To assess the quality of life of patients with different dermatophytoses. MATERIAL AND METHODS: Among 100 consecutive Indian patients with dermatophytosis, 76% agreed to participate. The diagnosis was established upon the typical clinical manifestation and direct microscopic mycological examination (10% KOH). Dermatology Life Quality Index (DLQI) was utilized to assess QoL impairment. Participants evaluated the presence and intensity of itch during the last 3 days using Numeral Rating Scale (NRS). RESULTS: A combination of tinea corporis and tinea cruris was diagnosed most commonly (52.6%), followed by tinea cruris alone (21%) and tinea corporis alone (13.2%). The mean duration of the disease was assessed as 6.3 ±18.0 months. The mean DLQI score was 8.2 ±5.1 points. A very large and extremely large effect on the DLQI was reported by 26.3% of patients, moderate by 40.8%, whereas small by 29%, with females being more heavily affected than males (9.3 ±5.2 and 7.1 ±4.7 points, respectively) (p = 0.038). Patients with a combination of tinea corporis, tinea cruris and tinea faciei demonstrated the lowest QoL (11.0 ±4.5 points). Additionally, a significant correlation between impairment of QoL and itch intensity (mean NRS score: 6.8 ±1.8 points) (r = 0.37; p < 0.002) was documented. Moreover, there was a trend towards lower QoL in patients who have been previously treated with topical agents containing corticosteroids. CONCLUSIONS: Superficial dermatophytoses are associated with a moderate impact on QoL of the affected subjects.

Alarming India-wide phenomenon of antifungal resistance in dermatophytes: A multicentre study.

BACKGROUND: An alarming increase in recalcitrant dermatophytosis has been witnessed in India over the past decade. Drug resistance may play a major role in this scenario. OBJECTIVES: The aim of the present study was to determine the prevalence of in vitro resistance to terbinafine, itraconazole and voriconazole in dermatophytes, and to identify underlying mutations in the fungal squalene epoxidase (SQLE) gene. PATIENTS/METHODS: We analysed skin samples from 402 patients originating from eight locations in India. Fungi were identified by microbiological and molecular methods, tested for antifungal susceptibility (terbinafine, itraconazole, voriconazole), and investigated for missense mutations in SQLE. RESULTS: Trichophyton (T.) mentagrophytes internal transcribed spacer (ITS) Type VIII was found in 314 (78%) samples. Eighteen (5%) samples harboured species identified up to the T interdigitale/mentagrophytes complex, and T rubrum was detected in 19 (5%) samples. 71% of isolates were resistant to terbinafine. The amino acid substitution Phe397Leu in the squalene epoxidase of resistant T mentagrophytes was highly prevalent (91%). Two novel substitutions in resistant Trichophyton strains, Ser395Pro and Ser443Pro, were discovered. The substitution Ala448Thr was found in terbinafine-sensitive and terbinafine-resistant isolates but was associated with increased MICs of itraconazole and voriconazole. CONCLUSIONS: The high frequencies of terbinafine resistance in dermatophytes are worrisome and demand monitoring and further research. Squalene epoxidase substitutions between Leu393 and Ser443 could serve as markers of resistance in the future.

The current Indian epidemic of superficial dermatophytosis due to Trichophyton mentagrophytes-A molecular study.

The disease burden of chronic-relapsing and therapy-refractory superficial dermatophytosis dramatically increased in India within the past 5-6 years. In order to evaluate the prevalence of this trend, 201 skin scrapings were collected from patients from all parts of India and were tested for dermatophytes using both fungal culture and a PCR-ELISA directly performed with native skin scrapings. Fungal culture material was identified by genomic Sanger sequencing of the internal transcribed spacer (ITS) region and the translation elongation factor (TEF)-1α gene. In total, 149 (74.13%) out of the 201 samples showed a dermatophyte-positive culture result. Out of this, 138 (92.62%) samples were identified as Trichophyton (T.) mentagrophytes and 11 (7.38%) as Trichophyton rubrum. The PCR-ELISA revealed similar results: 162 out of 201 (80.56%) samples were dermatophyte-positive showing 151 (93.21%) T mentagrophytes- and 11 (6.79%) T rubrum-positive samples. In this study, we show for the first time a dramatic Indian-wide switch from T rubrum to T mentagrophytes. Additionally, sequencing revealed a solely occurring T mentagrophytes "Indian ITS genotype" that might be disseminated Indian-wide due to the widespread abuse of topical clobetasol and other steroid molecules mixed with antifungal and antibacterial agents.

Male genital dermatophytosis - clinical features and the effects of the misuse of topical steroids and steroid combinations - an alarming problem in India.

Genital dermatophytosis has been considered rare by most Western authorities. However, to the contrary, Indian reports have shown a higher prevalence of genital dermatophytosis due to warm and humid climate, overcrowding and lack of hygiene. A review is presented for 24 cases of male genital dermatophytosis occurring in patients suffering from tinea cruris in India who have been randomly applying various broad-spectrum steroid antifungal and antibacterial creams containing one or more antifungal and antibiotic in addition to potent corticosteroids, mainly clobetasol propionate. This is such a common phenomenon that Indian dermatologists are witnessing an epidemic of sorts of steroid-modified dermatophytosis and we hereby share various clinical presentations of dermatophytosis of penis and/or scrotum in patients with tinea cruris who have been applying the above-mentioned creams. The review also discusses the bleak scenario that prevails in India regarding the drug regulatory affairs that allow such dangerous and irrational combinations that are sold over the counter because of misinterpretation of the law and lax implementation of existing laws.

Congenital Chikungunya--A Cause of Neonatal Hyperpigmentation.

A 12-day-old neonate presented with ill-defined dark pigmentation over the centrofacial area with flagellate pigmentation on the trunk and patchy pigmentation on the extremities. The mother had a history of fever starting a week before delivery and continuing for 3 days in the postpartum period. Together these led to consideration of a possible diagnosis of congenital chikungunya, which was confirmed according to the immunoglobulin M antibodies to chikungunya in the mother and child. The rare occurrence of cutaneous pigmentation was the only clue to the retrospective diagnosis of neonatal chikungunya. Chikungunya is an emerging viral disease that can be transmitted maternally during pregnancy and in the peripartum period. It can be added to the list of viral infections that can lead to fetal demise or, when present during labor and delivery, can cause neonatal disease with cutaneous signs.

Cutaneous vascular lesions and their management in Indian setting.

Indian skin with its broad range of skin color and complexion differs in the presentation and management of cutaneous vascular lesions. Common congenital and acquired vascular lesions are discussed with respect to the epidemiology, clinical presentation, and management strategies in an Indian setting. An effort has been made to review Indian case reports and studies of cutaneous vascular lesions, potential possible modification in the conventional treatment considering resource constraints, cultural practices, availability and cost-effectiveness of the laser and light sources, camouflage techniques, and sclerotherapy. The review concludes with emphasis on the need of availability of cost-effective, quality equipment customized to Indian skin and quality studies and trials for the management of cutaneous vascular lesions in an Indian setting.

The unprecedented epidemic-like scenario of dermatophytosis in India: II. Diagnostic methods and taxonomical aspects.

Trichophyton (T.) mentagrophytes now accounts for an overwhelming majority of clinical cases in India, a new "Indian genotype" (T. mentagrophytes ITS genotype VIII) having been isolated from skin samples obtained from cases across a wide geographical distribution in this country. The conventional diagnostic methods, like fungal culture, are, however, inadequate for diagnosing this agent. Thus, molecular methods of diagnosis are necessary for proper characterization of the causative agent. The shift in the predominant agent of dermatophytosis from T. rubrum to T. mentagrophytes, within a relatively short span of time, is without historic parallel. The apparent ease of transmission of a zoophilic fungus among human hosts can also be explained by means of mycological phenomena, like anthropization.

The unprecedented epidemic-like scenario of dermatophytosis in India: I. Epidemiology, risk factors and clinical features.

Dermatophytosis has attained unprecedented dimensions in recent years in India. Its clinical presentation is now multifarious, often with atypical morphology, severe forms and unusually extensive disease in all age groups. We hesitate to call it an epidemic owing to the lack of population-based prevalence surveys. In this part of the review, we discuss the epidemiology and clinical features of this contemporary problem. While the epidemiology is marked by a stark increase in the number of chronic, relapsing and recurrent cases, the clinical distribution is marked by a disproportionate rise in the number of cases with tinea corporis and cruris, cases presenting with the involvement of extensive areas, and tinea faciei.

The unprecedented epidemic-like scenario of dermatophytosis in India: III. Antifungal resistance and treatment options.

One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance between in vivo and in vitro resistance, demonstration of in vitro resistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.

Involvement of Little Discussed Anatomical Locations in Superficial Dermatophytosis Sundry Observations and Musings.

A rather quick change in epidemiological shift from Trichophyton rubrum to Trichophyton mentagrophytes (ITS genotype VIII), several changes in clinical presentation of superficial dermatophytoses and the the response/ the lack of it, makes this current epidemic very interesting and novel. We present here some of the relatively less discussed variants that have been described under the broad terms of tinea corporis and tinea faceie. Many of them are found to occur uncharacteristically frequently and some in areas that were never described. We describe some representative cases of female genital dermatophytoses, periumblical and periocular dermatophytosis and discuss some unusual variants like those showing sole involvement of the ear (tinea auricularis), lip (tinea labialis) and superficial dermatophytosis of the scalp skin.

Idiopathic Eruptive Macular Pigmentation - Uncommon Presentation of an Uncommon Condition.

Idiopathic eruptive macular pigmentation (IEMP) is an asymptomatic condition with dark brown, nonconfluent lesions chiefly occurring in children and adolescents. The usual sites involved are face, trunk, extremities, and the lesions resolve over few months to years. We report an unusual presentation of this uncommon condition. A 22-year-old male presented with multiple dark-colored asymptomatic lesions on the scalp and forehead for the past 3 years. There was no history of preceding symptoms, drug, or applications, past or family history of such lesions. Examination revealed multiple hyperpigmented macules and barely elevated nonscaly plaques with a velvety feel akin to acanthosis nigricans (AN). Dermoscopy was similar to AN. Blood sugar, thyroid, and lipid profiles were normal. Histology showed "pigmented papillomatosis" concluding the final diagnosis of IEMP. Confluence of lesions is a rarely described phenomenon, with the scalp being a hitherto unreported site. The velvety feel of lesions, the dermoscopic, and histopathological findings further substantiate the hypothesis of this entity being an eruptive variant of AN.

A descriptive study of facial acanthosis nigricans and its association with body mass index, waist circumference and insulin resistance using HOMA2 IR.

INTRODUCTION: The term facial acanthosis nigricans (FAN) lacks definition of precise clinical and histopathological features. We present a descriptive study of patients with FAN to define pigmentary patterns and estimate the prevalence of obesity and insulin resistance in these cases. MATERIALS AND METHODS: It is a prospective study that included all patients with classical AN of the neck and/or other areas with facial acanthosis nigricans described as brown-to-black macular pigmentation with blurred ill-defined margins, found on the zygomatic and malar areas. The body mass index (BMI) and waist circumference (WC) of the included patients were used as parameters of obesity. Homeostatic Model of Assessment of Insulin Resistance (HOMA2 IR) was used as a parameter to evaluate insulin resistance. Histopathological features of the 6 skin biopsies that were possible were reviewed. RESULTS: Among the 102 included individuals, the patterns of facial pigmentation seen in addition to the classic pattern involving zygomatic and malar areas were a hyperpigmented band on the forehead in 59.80%, periorbital darkening in 17.64%, perioral darkening in 12.74%, and generalized darkening in 9.8% of cases. 85.29% of the males and 100% of the females were found to be obese. Varying degrees of insulin resistance was noted in 82.34% of the individuals. Six biopsies available for evaluation showed changes such as mild epidermal hyperplasia with prominent basal melanin, however, without the typical papillomatosis seen in AN of the flexures. CONCLUSION: We document an increased prevalence of obesity and insulin resistance in patients presenting with FAN and its presentations in addition to the classical description. We propose that FAN can be considered a cutaneous marker of insulin resistance and that HOMA2 IR can serve as a parameter of insulin resistance in such cases.

Facial angiofibromas of tuberous sclerosis treated with topical sirolimus in an Indian patient.

Facial angiofibromas are the most visible and unsightly of all the cutaneous manifestations of tuberous sclerosis (TSC). A 17-year-old female, a known case of TSC, presented for the treatment of cosmetically disfiguring facial angiofibromas. She was started on twice daily application of 0.1% sirolimus ointment prepared from crushed tablets of sirolimus compounded in white soft paraffin. After 3 months of use, there was visible decrease in the erythema and the size of the angiofibromas. In an attempt to accelerate the response, the concentration was further increased to 1% sirolimus which was used for a month, resulting in a decrease not only in the size and redness but also in the number of the angiofibromas. The patient did not experience any cutaneous or systemic complications related to therapy. Sirolimus belongs to a novel class of anticancer drugs known as mTOR (mammalian target of Rapamycin) inhibitors. Sirolimus has been used as a targeted therapy for the renal and neurological manifestations of TSC. Topical preparation of sirolimus is not commercially available till date and hence preparations from crushed tablets or oral solution of sirolimus have been used with beneficial effects in treatment of angiofibromas especially in younger patients with flatter lesions. Randomized controlled trials are necessary to enable us to confirm the efficacy, long-term safety, the optimal dosage and possibility of reappearance once the drug is withdrawn. This is possibly the first case report of the use of topical sirolimus in India.