A cross-sectional study to analyze the clinical subtype, contact sensitization and impact of disease severity on quality of life and cost of illness in patients of hand eczema.

BACKGROUND: The high incidence, chronicity, frequent recurrences and severity of hand eczema leads to a massive impact on the quality of life. Despite great medical and socioeconomic importance, there is a paucity of data that addresses the cost of illness and economic factors associated with hand eczema. Most of the studies have originated from Europe and none have been reported from India. AIM: To analyze the clinical subtype, the pattern of contact sensitization and the impact of severity of disease on the quality of life and cost of illness in patients of hand eczema. METHODS: Hundred patients of hand eczema were recruited and evaluated for morphological patterns of the condition, hand eczema severity index and quality of life (Dermatology Life Quality Index questionnaire). All patients were subjected to patch tests with Indian standard series, cosmetic series and personal or work-related products. The economic burden of hand eczema was measured by both its direct and indirect costs. RESULTS: Morphologically, chronic dry fissured eczema 36 (36%) was the most common pattern followed by mixed type 19 (19%), hyperkeratotic palmar eczema 15 (15%), vesicular eczema with recurrent eruption 9 (9%), nummular eczema 7 (7%) and wear and tear dermatitis 7 (7%). Seventy nine patients gave positive patch test results. Etiological profile of the most common allergens, as established with a patch test, include potassium dichromate 18 (18%) followed by cetrimonium bromide 17 (17%), nickel 16 (16%), gallate 14 (14%), garlic 9 (9%) and patient's own product 8 (8%). Allergic contact dermatitis was the most common clinical pattern of hand eczema seen in 45 (45%) patients, followed by an irritant 14 (14%) and a combination of both 13 (13%). The average total cost of illness was INR 13,783.41 (0-93,000) per individual per year with an average direct cost of INR 2,746.25 ± 1,900 and indirect cost of INR 4911.73 ± 13237.72, along with a positive correlation with the Dermatology Life Quality Index (P = 0.00). The hand eczema severity index was marginally correlated with direct costs (P = 0.07) and highly correlated with indirect costs (P = 0.024). CONCLUSION: Hand eczema has a huge impact on the quality of life and economic consequences. LIMITATIONS: In our study, parameters like Dermatology Life Quality Index and hand eczema severity index could have been affected by the chronicity of disease as being a tertiary referral centre, most of the recruited patients had severe and persistent hand eczema at the time of visit. Also, cost of illness was based on retrospective calculations on recall basis.

Controlled trial comparing the efficacy of 88% phenol versus 10% sodium hydroxide for chemical matricectomy in the management of ingrown toenail.

BACKGROUND: Partial nail avulsion with lateral chemical matricectomy is the treatment of choice for ingrown toenails. Phenol (88%) is the most widely used chemical agent but prolonged postoperative drainage and collateral damage are common. Sodium hydroxide (NaOH) 10% has fewer side-effects. METHODS: Adult, consenting patients with ingrown toenails were alternately allocated into two treatment groups in the order of their joining the study, to receive either 88% phenol (Group 1, n = 26) or 10% NaOH (Group 0, n = 23) chemical matricectomy. The patients as well as the statistician were blinded to the agent being used. Post-procedure follow-up evaluated median duration of pain, discharge, and healing along with recurrence, if any, in both the groups. The group wise data was statistically analyzed. RESULTS: Both the groups responded well to treatment with the median duration of postoperative pain being 7.92 days in Group 0 and 16.25 days in Group 1 (P < 0.202). Postoperative discharge continued for a median period of 15.42 days (Group 0) and 18.13 days (Group 1) (P < 0.203). The tissue condition normalized in 7.50 days (Group 0) and 15.63 days (Group 1) (P < 0.007). LIMITATIONS: Limited postsurgical follow up of 6 months is a limitation of the study. CONCLUSION: Chemical matricectomy using NaOH is as efficacious as phenolisation, with the advantage of faster tissue normalization.

Profile of oxidative stress in response to treatment for type 1 leprosy reaction.

OBJECTIVE: To measure oxidative stress in Type 1 leprosy reaction, and to document the effect of anti-leprosy multidrug therapy (MDT) and anti-reaction drugs on measures of oxidative stress. MATERIALS AND METHODS: A prospective study was carried out at a teaching hospital involving consecutive patients with Type 1 reaction. MDA (malondialdehyde), FRAP (ferric reducing ability of plasma) and GSH (reduced glutathione) were measured in venous blood samples as measures of oxidative stress and compared at inclusion, after 4 weeks of initial therapy (following standard guidelines including MDT, NSAIDS, and systemic steroids), and 4 weeks after clinical remission. RESULTS: The final study cohort included 40 patients with Type 1 reaction (different treatment arms) after excluding for confounding factors such as prior treatment, smoking, NSAID use or concurrent illness requiring therapy. Measures of lipid derived oxidative stress assessed by MDA showed a significant rise with 4 weeks of therapy and a trend towards decline after clinical resolution. In contrast, the other two measures of anti-oxidants namely GSH and FRAP, showed a significant decrease (P < 0.05) at 4 weeks of treatment followed by a significant increase after 4 weeks of clinical remission of reaction. CONCLUSION: MDT and anti-reactional treatment is associated with significant increases in FRAP and GSH levels, reflecting a reduction in the oxidative stress in patients treated for Type 1 reaction. However, lipid peroxidation as measured by MDA is only partially controlled with treatment.

Leprosy Scenario at a Tertiary Level Hospital in Delhi: A 5-year Retrospective Study.

BACKGROUND: Leprosy has been officially eliminated from India since December, 2005; still, there are districts and blocks reporting high prevalence indicating ongoing transmission. The present study aimed at determining the current clinical profile of leprosy from a tertiary level hospital in Delhi. MATERIALS AND METHODS: A retrospective, record-based study was carried out on patients diagnosed and registered in the leprosy clinic of a tertiary level teaching hospital in East district of Delhi (April 2007 to March 2012). Data regarding demographic details, clinical features, treatment started and complications was analyzed. RESULTS: A total of 849 patients were registered over a 5-year period, with M: F ratio of 2.3:1. 9.3% were children (≤14 years). 54.3% patients were immigrants from adjoining states. Multibacillary leprosy was the most common clinical type (86.9%). Borderline tuberculoid leprosy was the most frequent morphologic type, seen in 56.3% followed by borderline-borderline (1.5%), borderline lepromatous (24.9%), lepromatous leprosy (8.1%), pure neuritic (8.1%), histoid and indeterminate leprosy (0.5% each). 37.4% patients presented in reaction (Type I in 30.4% cases and Type II in 7% cases). WHO grade II deformities were diagnosed in 37.9% with claw hand being the most common paralytic deformity (23.3% cases). CONCLUSION: Our study offers insight into the current status of the disease in an area of otherwise low prevalence. It is seen that despite statistical elimination, multibacillary disease, leprosy reactions and deformities are commonly seen as presenting manifestations, in contrast to national projected trends. Delhi's unique demography with a high degree of migrant workers, presenting to our center (near border location) could be a possible contributing factor towards these aberrations. It highlights the need for continuation of targeted leprosy control activities and active case detection.

Menstrual irregularities, fertility status, and ovarian function in female patients with leprosy in India.

BACKGROUND: Gonadal involvement in males in lepromatous leprosy is not uncommon, but there is a paucity of literature on the involvement of gonads in female patients with leprosy. This study was undertaken to determine if there is any menstrual dysfunction, alteration in fertility status and circulating luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and estradiol in female patients with paucibacillary (PB) and multibacillary (MB) leprosy. MATERIALS AND METHODS: In a cross-sectional study, 229 patients with leprosy (79 with PB leprosy and 150 with MB leprosy) and 100 age-matched non-leprosy controls were evaluated for menstrual function, fertility status, and circulating sex hormones. RESULTS: Twenty percent of patients with MB leprosy had menstrual irregularities post-dating the onset of leprosy in comparison to 6.3% patients with PB leprosy, and this difference was statistically significant (P < 0.001). However, the fertility profile of patients with PB leprosy was comparable to that of patients with MB leprosy (P > 0.05). A significantly higher number of patients with MB leprosy (9.3%) had elevation of circulating FSH, LH, and prolactin vis-à-vis patients with PB leprosy (1.3%), and this difference was statistically significant (P < 0.05). Similarly, the mean levels of LH, FSH, and prolactin were significantly elevated in patients with MB leprosy vis-à-vis patients with PB leprosy and controls (P < 0.05). CONCLUSIONS: Multibacillary leprosy may be associated with menstrual irregularities and elevation of gonadotropin hormones, indicating an ovarian dysfunction.

IL12B SNPs and copy number variation in IL23R gene associated with susceptibility to leprosy.

BACKGROUND: Genome-wide studies have identified both human leucocyte antigen (HLA) and non-HLA regions in association with leprosy. Involvement of novel functional loci within these regions has been proposed by us earlier. METHODS: We investigated the role of 23 single nucleotide polymorphisms (SNPs) in IL12B and IL12RB2 in a total of 2345 individuals from India, using MassArray platform, along with the copy number variations in IL23R, IL12RB2 and IL10 genes in a representative set of 257 individuals, using real-time PCR. RESULTS: SNP rs2853694 in IL12B gene (AA vs AC+CC, p=2.6E-04, OR=1.42 (1.17-1.70)) showed an association with leprosy. Pairwise interaction analysis followed by combined analysis of multiple SNPs identified that IL12B, TNF and BTNL2-DRA inter-genic SNPs provided a major risk towards leprosy (p=2.6E-08, OR=3.94 (2.43-6.38)), showing a further increase (p=3.6E-14) for combined risk genotype interactions. On the other hand, IL12B, BAT1, NFKBIL1 and LTA SNPs together showed a disposition towards protection (p=0.000011, OR=0.32 (0.19-0.53)) with a further increase (p=6.38E-10) for combined protective genotype-interactions. Copy number variation analysis showed an increased copy number of the IL23R gene (PB=36.4%, controls=20.2%; p=0.026) associated with the pauci-bacillary form of leprosy, which correlated with a trend towards enhanced expression in memory T cells in a preliminary observation. CONCLUSIONS: The observations made here highlight the importance of interaction between specific genetic backgrounds of immune response related genes in the outcome of Mycobacterium leprae infection.

Oxidative stress and leukocyte migration inhibition response in cutaneous adverse drug reactions.

BACKGROUND: Cutaneous adverse drug reactions (CADRs) may either be immunological or non-immunological. The precise mechanisms, however, are largely obscure. Other concomitant mechanisms may amplify and/or contribute to the severity and duration of a reaction. One such mechanism could be oxidative stress, a state of imbalance between reactive oxygen species, and their subsequent detoxification by antioxidants. AIMS: (a) to assess the oxidative stress status in the blood of cutaneous drug reaction patients by assaying for reduced glutathione (GSH) and malondialdehyde (MDA) levels, (b) to determine the leukocyte migration inhibition (LMI) response in these patients in response to the suspected drug (s), and (c) to look for the association between oxidative stress parameters and LMI. METHODS: Ethical committee approval was obtained for this study. Fresh venous blood samples were obtained from the patients of CADRs (group A) during the acute phase of reaction and healthy control subjects (group B). MDA levels, a measure of oxidative lipid damage, and reduced GSH levels, a measure of anti-oxidant capacity, were assayed in the blood samples of both groups using spectrophotometry. LMI response was measured by challenging the patients' peripheral blood mononuclear cells with the suspected drug to confirm immunological perturbation. RESULTS: Totally 66 participants, 33 cases in group A and equal number of controls in group B, were studied. The mean MDA levels were found to be raised (P < 0.001), but GSH levels were significantly reduced in group A when compared with group B (P = <0.001). LMI response against drug(s) was performed in 33 cases (group A), out of which 25 cases showed a positive LMI response as follows: fixed drug eruption (10/25), SJS (5/25), urticaria (3/25), exfoliative dermatitis (2/25), morbilliform rash (2/25), erythroderma (1/25), vasculitis (1/25), and dapsone syndrome (1/25). The mean MDA levels were found to be significantly higher in the LMI positive CADRs (P < 0.001) when compared with LMI-negative ones, while no significant difference was seen for GSH (P = 0.100). Furthermore, there was a significant positive correlation between MDA levels and LMI response (r = 0.831, P < 0.001). On the other hand, a negative but statistically insignificant correlation was found between GSH and LMI response (r = -0.248, P = 0.271). CONCLUSION: CADR patients were found to be under oxidative stress based on MDA and GSH levels in the peripheral blood. There is a significant positive correlation of LMI response (against the causative drug) with MDA levels, which strongly associates oxidative stress with the immunopathogenesis in CADRs.

Computer Assisted Objective Structured Clinical Examination: a useful tool for dermatology undergraduate assessment.

BACKGROUND: Dermatology is a minor subject in undergraduate medical curriculum in India. The dermatology clinical postings are generally poorly attended, and the clinical acumen of an average medical graduate in this specialty is quite low. AIMS: To develop and implement Computer Assisted Objective Structured Clinical Examination (CA-OSCE) as a means of end of dermatology posting evaluation. Also, to assess its effectiveness in improving the motivation, attendance and learning of undergraduate students with respect to their visual recognition skills and problem solving ability. METHODS: We designed and introduced CA-OSCE as a means of end of posting assessment. The average attendance and assessment scores of students undergoing CA-OSCE were compiled and compared using 'independent t test' with the scores of previous year's students who had undergone assessment with essay type questions. RESULTS: The average attendance and average assessment scores for the candidates undergoing CA-OSCE were found to 83.36% and 77.47%, respectively as compared to 64.09% and 52.07%, respectively for previous years' students. The difference between the two groups was found to be statistically significant. Student acceptability of the technique was also high, and their subjective feedback was encouraging. CONCLUSION: CA-OSCE is a useful tool for assessment of dermatology undergraduates. It has the potential to drive them to attend regularly as well as to test their higher cognitive skills of analysis and problem solving.

A study of clinicohistopathological correlation in patients of psoriasis and psoriasiform dermatitis.

BACKGROUND: Psoriasis has different clinical variants, which mimic diverse dermatological conditions and may require a histopathological confirmation of the diagnosis. Studies to establish a clinicohistopathological concordance (and its determinants), in psoriasis and psoriasiform dermatitis are lacking. AIMS: The present study was designed (a) to correlate the clinicohistopathological features of psoriasis and psoriasiform dermatitis, and (b) to identify determinant(s) that may contribute to the diagnosis of psoriasis and psoriasiform dermatitis. METHODS: This was a prospective study involving 100 patients, with a single clinical diagnosis of psoriasis or with psoriasis as one of the differential diagnoses, and its correlation with histopathological features. RESULTS: The clinical features of typical scale (P = 0.0001) and Auspitz's sign (P = 0.0001), and histological evidence of suprapapillary thinning (P = 0.0001) and absent granular cell layer (P = 0.0001) were found to be statistically significant contributors to the clinicohistological concordance in cases of psoriasis. Vertical orientation of collagen bundles (P = 0.0001) and lymphocytic exocytosis (P = 0.003) were found to be significantly associated with diagnosis of psoriasiform dermatitis. CONCLUSION: The present study reconfirms the diagnostic accuracy of silvery white scale, Auspitz's sign, and Koebner's phenomenon in a clinical setting suggestive of psoriasis. However, in their absence, histological evidence of suprapapillary thinning and absent granular layer, in addition to the Munro microabscess and Kogoj's abscess, may contribute to the diagnosis of psoriasis. Similarly, vertical orientation of collagen bundles and lymphocytic exocytosis may point toward a diagnosis of psoriasiform dermatitis.

Dermatitis herpetiformis and rheumatoid arthritis.

A 35- year-old deaf and dumb woman with clinical and histopathological diagnosis of dermatitis herpetiforrnis (DH) is reported for its rare association with rheumatoid arthritis (PA).