Sclerotherapy in the management of varicose veins and its dermatological complications.

BACKGROUND: Varicose veins and its dermatological complications like stasis dermatitis, ulcers, spontaneous bleeding are commonly seen in the dermatology clinics. Surgery has been the most often used treatment for varicose veins. Sclerotherapy refers to introduction of sclerosing solution into the varicose veins, which causes endothelial damage and subsequent fibrosis. Sclerotherapy is being practised extensively by dermatosurgeons in the west. However, there are no Indian studies which specifically evaluate the role of sclerotherapy in the management of varicose veins and its skin complications. Hence, this study aims to evaluate the efficacy of sclerotherapy in managing varicose veins and its complications. AIMS: To study the safety and efficacy of sclerotherapy in the treatment of varicose veins and its dermatological complications. METHODS: This is a prospective study involving 50 patients with varicose veins and its dermatological complications attending the dermatology out-patient department. The study was conducted over a period of 18 months. After thorough clinical, laboratory, and radiological evaluation, the patients were treated with sclerotherapy using Sodium Tetradecyl Sulphate of various concentrations depending on the vessel size. The patients were then followed up to look for disappearance of veins, healing of ulcers and eczema, and any complications. RESULTS: Patients showed a good response to treatment with sclerotherapy. 70-80% of patients showed symptomatic improvement along with disappearance of veins and healing of eczema and ulcers. Most of the complications were minor, which resolved over a period of few weeks. CONCLUSION: Sclerotherapy is a simple, safe and effective procedure for the treatment of varicose veins and its dermatological complications. The procedure is particularly effective for smaller, early varicosities and also for residual veins after surgery. Hence we recommend more and more of our fellow dermatologists to take up this procedure, which can be an efficient tool to manage patients with varicose veins and its related complications.

Standard guidelines for care: sclerotherapy in dermatology.

DEFINITION: Sclerotherapy is defined as the targeted elimination of small vessels, varicose veins and vascular anomalies by the injection of a sclerosant. The aim of sclerotherapy is to damage the vessel wall and transform it into a fibrous cord that cannot be recanalized. It is a simple, cost-effective, efficacious and esthetically acceptable modality for both therapeutic and esthetic purposes. INDICATIONS: Therapeutic indications include varicose veins and vascular malformations. Esthetic indications include telangiectasias and reticular veins. In the management of varicose veins, it may need to be combined with other surgical methods of treatment, such as ligation of the saphenofemoral junction, stab ligation of perforators and stripping. A surgical opinion may be necessary. METHODOLOGY: A thorough knowledge of the anatomy and physiology of the venous system of the legs, basic principles of venous insufficiency, methods of diagnosis and, in addition, uses, mechanisms of action and complications of sclerosing agents and proper compression techniques are important pre-requisites to successful sclerotherapy. Although various sclerosing agents are available, polidoconal and sodium tetradecyl sulfate are most commonly used. More recently, these sclerosants have been used in microfoam form for increased efficacy. The basic principle of a successful sclerotherapy technique is the use of an optimal volume and concentration of the sclerosant according to the size of the vessel. The sclerosant is injected carefully into the vessel and compression is applied. CONTRAINDICATIONS: Contraindications include superficial and deep venous thrombosis, sapheno-femoral junction incompetence, pregnancy, myocardial decompensation, migraine, hypercoagulable state, serious systemic illness, dependency edema, immobility, arterial disease, diabetes mellitus and allergic reactions to sclerosants. COMPLICATIONS: While sclerotherapy is usually a safe procedure, complications may occur due to inappropriate patient selection or improper injection techniques. The complications may be acute or delayed. Complications include hyperpigmentation, matting, local urticaria, cutaneous necrosis, microthrombi, accidental intra-arterial injection, phlebitis, deep vein thrombosis, thromboembolism, scintillating scotomas, nerve damage and allergic reactions. PHYSICIAN QUALIFICATION: Sclerotherapy may be administered by a surgeon or dermatologist who has acquired adequate training during post-graduation or through recognized fellowships and workshops dedicated to sclerotherapy. He should have an adequate knowledge of the anatomy of the venous system, be able to diagnose and manage venous disease and its associated consequences as well as possess the necessary skills to perform the procedures, understand the appropriate indications and limitations, technique modifications and management of the potential adverse sequelae associated with sclerotherapy and also understand the pharmacology of the sclerosing solutions. FACILITY: The procedure may be performed in the physician's procedure room.

Comparative study of efficacy and safety of hydroxychloroquine and chloroquine in polymorphic light eruption: a randomized, double-blind, multicentric study.

BACKGROUND: Polymorphic light eruption is the most common photodermatosis characterized by nonscarring, pruritic, erythematous papules and plaques. AIM: To evaluate the efficacy and safety of hydroxychloroquine in comparison with chloroquine in patients suffering from polymorphic light eruption. METHODS: This was a randomized, double-blind, comparative, multicentric study conducted at two centers. This study enrolled 68 (58.1%) males, 49 (41.8%) females whose ages ranged from 18-73 years and average weight was 57.89 +/- 8.27 kg. A total of 117 patients were enrolled in the study. Out of 117 patients, 63 patients were randomized to receive hydroxychloroquine tablets 200 mg twice daily for the first month and 200 mg once daily for the next month. Similarly, 54 patients were randomized to receive chloroquine tablets 250 mg twice daily for the first month and 250 mg once daily for the next month. The total duration of therapy for both the study arms was two months. The severity and frequency of burning, itching, erythema and scaling were evaluated at predetermined intervals (at baseline, after four, eight and 12 weeks of therapy). RESULTS: A significant reduction in severity scores for burning, itching and erythema was observed in patients treated with hydroxychloroquine than with chloroquine (P P = 0.229). The good to excellent response was reported by 68.9% of the patients who received hydroxychloroquine and by 63% of the patients who received chloroquine. The adverse events reported were mild to moderate and none of the patients reported any serious adverse events or ocular toxicity in this study. CONCLUSION: Hydroxychloroquine was found to be significantly more effective than chloroquine in the treatment of polymorphic light eruption and can be used safely in the dosage studied in such patients with little risk of ocular toxicity.

Niosomal methotrexate gel in the treatment of localized psoriasis: phase I and phase II studies.

BACKGROUND: Efficacy of topical methotrexate in psoriasis is limited by its penetration. AIMS: The study involved the preparation of niosomal methotrexate in chitosan gel and to test the same for irritation and sensitization on healthy human volunteers followed by assessing the efficacy of the gel through double-blind placebo-controlled study on psoriasis patients and also comparing its efficacy with a marketed methotrexate gel. METHODS: The methotrexate niosomes were prepared by lipid layer hydration method. The characterized niosomes were incorporated in chitosan gel. The gels were tested on 10 human volunteers to check for irritation and skin sensitivity by human repeated insult patch test (HRIPT). The formulations were assessed for efficacy by double-blind placebo-controlled study in 10 psoriasis patients for each formulation. The efficacy was calculated by psoriasis area and severity index scoring method. The global score was used to assess the progress of the disease. RESULTS: The HRIPT test did not produce any significant irritation or sensitization on healthy human volunteers. The placebo and marketed gels were compared with niosomal methotrexate gel. At Week 12, with niosomal methotrexate gel, there was reduction in total score from 6.2378+/-1.4857 to 2.0023+/-0.1371. CONCLUSION: These results suggest that niosomal methotrexate gel is more efficacious than placebo and marketed methotrexate gel.

A comparative evaluation of skin and nerve histopathology in single skin lesion leprosy.

BACKGROUND: In spite of leprosy being a disease of nerves, ROM therapy for single skin lesion leprosy was based on clinical trials without much evidence-based studies of nerve pathology. The present study was undertaken to compare the histology of skin and nerve in single skin lesion leprosy, and to assess the scientific rationale and justification of single dose ROM therapy. METHODS: Twenty-seven untreated patients with single skin lesion without significantly thickened peripheral nerves were selected. Skin and nearby pure cutaneous nerve biopsies were studied under both H&E and Fite's stain. RESULTS: All the skin biopsies were negative for AFB and clinico-pathological correlation was positive in 51.85% of skin biopsy specimens. Histopathological diagnosis of leprosy was evident in 55.5% of clinically normal looking nerves, with AFB positivity in 29.6% of nerve biopsy specimens. Correlation between clinical diagnosis and nerve histopathology was poor (26%). CONCLUSIONS: Single skin lesion without thickened peripheral nerves as criteria for single dose ROM therapy is not logical, since the histological diagnosis of leprosy in normal looking nerves with presence of AFB is revealed in this study. Pure cutaneous nerve biopsy is a simple outpatient procedure, without complications. This study emphasizes the need to consider nerve pathology as an important tool for further therapeutic recommendations, than just clinical trials and skin pathology alone. Though single dose ROM therapy has been withdrawn recently, the principle holds good for any future therapeutic recommendations.

Role of modified rapid AFB method in histopathological sections of Hansen's disease.

Leprosy is a chronic debilitating disease. A reliable diagnosis hinges around a good histopathological diagnosis and demonstration of the bacilli in the histopathological section. The usual method performed Modified Fite Faraco Method is time consuming, laborious and less sensitive. It has been our endeavor to devise a more rapid and sensitive method for the diagnosis and bacillary load detection in histopathological sections. The Modified Rapid AFB devised by us is sensitive and time saving which is essential for the pathologist and for the treatment by the Dermatologist. We have studied about 53 cases of different types of Hansen's disease and compared with both Modified Fite Faraco method and Modified Rapid AFB method. The results were found to be very encouraging with the Modified Rapid AFB method.