Autologous serum therapy in chronic urticaria: old wine in a new bottle.

BACKGROUND: Chronic urticaria (CU) is one of the most challenging and frustrating therapeutic problems faced by a dermatologist. A recent demonstration of abnormal type 1 reactions to intradermal autologous serum injections in some CU patients has led to the characterization of a new subgroup of "autoimmune chronic urticaria". This has rekindled interest in the age-old practice of autologous blood injections as a theoretically sound treatment option in these patients. AIMS: To evaluate the efficacy of repeated autologous serum injections (ASIs) in patients with recalcitrant chronic urticaria. METHODS: A cohort of 62 (32 females) CU patients with a positive autologous serum skin test (ASST) (group 1) was prospectively analyzed for the efficacy of nine consecutive weekly autologous serum injections with a postintervention follow-up of 12 weeks. Another group of 13 (seven females) CU patients with negative ASST (group 2) was also treated similarly. In both groups, six separate parameters of disease severity and activity were recorded. RESULTS: Demographic and disease variables were comparable in both groups. The mean duration of disease was 1.9 +/- 0.3 years (range = 3 months to 32 years) in group 1 and 1.5 +/- 0.2 years (range = 3 months to 10 years) in group 2. In the ASST (+) group, 35.5% patients were completely asymptomatic at the end of the follow-up while an additional 24.2% were markedly improved. In the ASST (-) group, these figures were 23 and 23% respectively. The intergroup difference for complete subsidence was statistically significant (P < 0.05). In both groups, the most marked reduction was seen in pruritus and antihistamine use scores followed by the size and frequency of the wheals. CONCLUSION: Autologous serum therapy is effective in a significant proportion of ASST (+) patients with CU. A smaller but still substantial number of ASST (-) patients also benefited from this treatment.

Patch testing experience with 1000 patients.

BACKGROUND: Patch testing is a definitive tool for diagnosing allergic contact dermatitis (ACD). It reveals the prevalence and trends of contact sensitization in the community, thereby paving the way for better standard series. There is paucity of large series of patch-tested patients from India. AIM: To report the 9-year patch-test data from a single general dermatology centre in North India. METHODS: Consecutive patients presenting with signs/symptoms of suspected ACD were patch tested from May 1997 to April 2006. The Indian Standard Series was used. Parthenium was tested only in selected patients and cetrimide and chloroxylenol were added to the series. RESULTS: In total, records of 1000 patients (566 male, 434 female) were analyzed, yielding 1155 positive reactions in 590 (59%) patients. Footwear dermatitis was the commonest suspected diagnosis, followed by ACD to medicaments, cosmetic dermatitis and plant dermatitis. Out of the allergens that were tested in all the patients, positivity to nickel was the commonest (12.9%), followed by potassium dichromate (11.1%) neomycin (7%), mercaptobenzthiazole (6.6%), nitrofurazone (6%), colophony (5.7%), fragrance mix (5.5%) and cobalt chloride (5.4%). However, parthenium was the commonest allergen based on the proportion of patients tested with it (14.5%). In men, potassium dichromate (30%) was the commonest sensitizer and in women, nickel (43%) was the commonest to show patch-test positivity. CONCLUSION: Our study revealed higher prevalence of footwear and medicament dermatitis in comparison to existing data. Allergy to antiseptics is significant in our patients. Further collaborative studies involving patients from other parts of India are required to have an overall view of ACD in India.

Leiomyomas in a naevoid distribution.

A 59-year-old man developed gradually appearing and slowly progressive tender papulo-nodular lesions in a naevoid distribution on the left side of the trunk since the age of 49 years. The histopathological features were classical of leiomyoma.

Helicobacter pylori and associated histopathological changes in gastric biopsies of patients with leprosy.

Two antral biopsies each from 104 patients of leprosy and 100 controls were studied to find out the prevalence of H. pylori and associated histopathological changes. Sections were stained with hematoxylene and eosin, AB/PAS (Ph 2.5) and Loeffler's methylene blue stains. Infection by H. pylori, inflammation and atrophy were found to be significantly more in leprosy patients as compared to controls (p < 0.01, < 0.005 and < 0.02 respectively). On comparing the histopathological changes in various subgroups of leprosy, H. pylori, inflammation and activity showed a statistically decreasing trend from tuberculoid to lepromatous subgroups (p < 0.05, < 0.001, < 0.01 respectively). Atrophy showed a significant increasing trend from tuberculoid to lepromatous group (< 0.001), it is concluded that despite a low prevalence of H. pylori and associated gastritis in patients with lepromatous leprosy, gastric epithelial damage is more marked due to altered immune response.

Clinico-histopathological concordance in leprosy.

Histopathological examination of biopsies from 111 patients with clinically diagnosed leprosy was carried out in order to observe the clinico-histopathological correlation. Clinical diagnosis was based on Ridley and Jopling (R-J) classification and World Health Organization (WHO) classification. The concordance rate between the two clinical classifications was 73.8%. Sections were stained with haematoxylin and eosin (H&E) and Ziehl-Neelsen's (Z-N) stains. The histological classification was as per the R-J criteria. Skin biopsy showed evidence of leprosy in 104 cases (93.69%). Overall concordance was observed in 58.6% (R-J) and 85.6% (WHO classification). The kappa test, when applied, showed significant agreement between clinical and histopathological diagnosis (z=11.775; P<0.001). Individual subtypes showed variable concordance rates which were again higher using WHO classification. When some of the subtypes were combined, the concordance rate was 83.02% for TT+BT; 72.58% for BT+BB+BL; 73.91% for BL+LL; 80.77% for BL+HL and 100% for LL+HL. (See Introduction for definitions of abbreviations.) The present study highlights the importance of histopathological examination for exact subtyping of leprosy, so as to facilitate the institution of accurate mode of therapy and regular follow-up of patients to prevent undesirable complications.

Autologous miniature skin punch grafting in vitiligo.

Forty-five sites of stable vitiligo in 32 patients refractory to medical treatment were subjected to autologous miniature skin punch grafting. Main instruments used were skin biopsy punches 1-3 mm in diameter. Donor sites selected were either gluteal region or extensor aspect of the thigh which were not affected by the disease in the past. Most of the grafts changed from brown to black and upper scales desquamated within 10-15 days. Uniform perigraft pigmentation was observed by 1-1½ months and 90% area was covered within 3-4 months. The cases were followed up for six months. Fair to excellent results were observed in 87.5% of the cases.

Clinical profile and electrodiagnostic study of peripheral neuropathy.

A clinical analysis and electrophysiological study was performed in 40 cases of peripheral neuropathy. Motor nerve conduction velocity (MNCV) and electromyography (EMG) were also recorded in 20 healthy volunteers. Twelve cases were of diabetic neuropathy (DN), nine of Guillain-Barre syndrome (GBS), eight of idiopathic, six of leprous, three of toxic neuropathy and one each of acute intermittent porphyria (AIP) and carcinomatous neuropathy. The onset was insidious in a majority of the cases (70%), the presenting symptom being paraesthesia (27.5%). A variable sensory loss was the commonest finding (77.5%). Two patients each had evidence of cranial nerve involvement and affection of urinary bladder and bowel. In both DN and GBS there was a significant reduction in the MNCV especially in the peroneal nerves. In DN 41.6% had evidence of decreased motor unit potentials and 16.6% showed spontaneous fibrillatory activity. For GBS these figures were 77.7% and 8.3% respectively. The peripheral nerve involvement was variable in leprosy and the EMG was normal in all, but one case.

Atrophoderma Vermicularis.

Three siblings of a family developed atrophoderma vermicularis, presenting as itchy, keratotic follicular papules all over the body mainly on the extensor aspect of the extremities and multiple atrophic pits involving the face and atrophic scars on other areas of the body.

Pseudo-ainhum Associated with Spina-bifida Occulta and Hemivertebra.

A 7 year old girl had pseudo-ainhum, spina-bifida occulta, A hemivertebra and focal, neurogical deficit. The disease process was progressive for the last three years leading to amputation of the third digit and formation of constricting bands around -the fourth and the fifth digits of the left foot.

Familial Biphasic Cutaneous Amyloidosis.

A Bengali family had familial biphasic cutaneous amyloidosis in 6 of the 11 members in 3 generations. The propositti developed intense itching, thickening and pigmentation of the skin associated with discrete, brownish black papules bilaterally on the legs, ankles, popliteal fossae and extensor aspects of the thighs. Face, neck, scalp and oral mucosa were spared. There was hyperkeratosis of the palms and soles. None of them had lymphadenopathy, macroglossia, hepatosplenomegaly, neuropathy or gingival hypertrophy.

Antispermatozoal antibodies in leprosy with special reference to their morphological patterns.

Sixty two male patients with polar leprosy--38 lepromatous and 24 tuberculoid types were investigated for the presence of antispermatozoal antibodies with special reference to their morphological patterns. Antibodies were detected by three different immunological techniques. Sperm agglutination was found to be the most sensitive. The incidence of antibodies was higher in patients with lepromatous leprosy and was directly proportional to the duration of the disease in both types of leprosy. Morphologically, head-to-head type of agglutination was observed in 50 percent of the patients, mixed in 41.7 percent and tail-to-tail type in 8.3 percent. There was no correlation between the number of ENL attacks and the incidence of anti-bodies. In polar tuberculoid leprosy patients the histological findings of testicular biopsy indicated cell mediated tissue damage occurring in a non-infective form.

Scleromyxedema.

Scleromyxedema was observed in a 43 year old male. PATIENT: The lesions were shiny, waxy-looking, soft,, papules, 2 to 4 mm in diameter and were most marked on the neck and ear lobules. There was no evidence of paraproteinemia.

Paraben Contact Hypersensitivity.

One hundred patients suspected to be having contact hypersensitivity to topical medicaments were patch tested with methly and propyl parabens along with commercially available topical medicaments. Six patients showed positive reactions to parabens. Two patients each were positive to methyl paraben and propyl paraben and two showed positive reactions to both of these. Three patients each showed positive reactions to soframycin, econazole and nitrofurazone also.

Incidence of Contact Hypersensitivity and Cross Sensitivity of Neomycin Group of Antibiotics.

One hundred consecutive patients suspected to have contact dermatitis due to topical medicaments were patch tested with 20% neomycin, framycetin, gentamicin as well as other commercially available antibacterial agents. Neomycin sensitivity was observed in 16.0% cases, while framycetin and gentamicin sensitivity was seen in 11.0% and 4.2% respectively. Fifty percent neomycin hypersensitive cases cross - reacted with framycetin and 22.00/o cross reactivity was observed with getamicin.

A study of blood ascorbic acid in leprosy.

The basal level of blood ascorbic acid was studied in 70 cases of polar leprosy. The level was found to be significantly reduced in both polar types, more so in tuberculoid. In untreated cases of these two polar forms, the differences were highly significant. No significant differences were found between untreated and treated cases of either form of leprosy, indicating that dapsone (DDS) has no effect on the ascorbic acid level. In lepromatous leprosy, the level was not affected by erythema nodosum leprosum (ENL). The deficiency of ascorbic acid in leprosy might be due to the disease per se and/or associated with nutritional factors. In trophic ulcers after supplement therapy for 60 days, the low level of ascorbic acid became close to the control group with marked improvement in the healing of the ulcers clinically. In addition, lactic and pyruvic acids were also measured and found to be significantly raised. After ascorbic acid supplement, the levels fell to near the control values, indicating that ascorbic acid played a role in controlling the infection as well as possible thiamine deficiency and also checked the disturbance caused by DDS on lactate and pyruvate metabolism. The present study suggested that supplementing DDS therapy with ascorbic acid might provide a beneficial effect on the general condition of the leprosy patients and the early healing of trophic ulcers.