Validation of the diagnostic criteria for segmental vitiligo.

BACKGROUND: Segmental vitiligo has a different clinical course and prognosis as compared to nonsegmental vitiligo, which necessitates its correct diagnosis. It may be difficult to distinguish segmental vitiligo from the limited or focal types of nonsegmental vitiligo. OBJECTIVE: To validate the previously proposed diagnostic criteria for segmental vitiligo. METHODS: This was a cross-sectional validation study involving patients with limited vitiligo. The diagnostic criteria were used to classify vitiligo lesions as segmental or nonsegmental, and was compared with the experts' diagnosis, which was considered as the "gold standard". RESULTS: The study included 200 patients with 225 vitiligo lesions. As per the diagnostic criteria, 146 vitiligo lesions were classified as segmental and 79 as nonsegmental. The experts classified 147 vitiligo lesions as segmental and 39 as nonsegmental, while the diagnosis either was labeled "unsure" or could not be agreed upon for 39 lesions. As compared with the experts' opinions ("for sure" cases, n = 186), the sensitivity and specificity of the diagnostic criteria was 91.8% (95% confidence interval [CI]: 86.2%-95.7%) and 100% (95% CI: 91%-100%), respectively. The positive predictive value was 100% (95% CI: 97.3-100%), while the negative predictive value was 76.5% (95% CI: 62.5%-87.2%). There was a 93.5% agreement between the clinical criteria and experts' opinions (k = 0.83, P < 0.001). LIMITATION: The diagnostic criteria were compared with the experts' opinion in the absence of an established diagnostic "gold standard". CONCLUSIONS: The proposed diagnostic criteria for segmental vitiligo performed well, and can be used in clinical practice, as well as in research settings.

Therapeutic potential of biosimilars in dermatology.

The introduction of biologic therapy has revolutionized the treatment of many chronic diseases, including several dermatological disorders. Biological agents promise to satisfy medical needs previously unmet by conventional medicines. Unfortunately, these agents are expensive and out of reach for the majority of patients who need them. Biosimilars are copies of the innovator biological agents and represent an important advance in the field of biological therapeutics. Although they are similar to the original biologic, differences in terms of structure, efficacy, safety and immunogenicity remain a concern. Thus, biosimilars cannot be regarded as bio-generics. Awareness of the key differences between a biosimilar and its reference biological agent is essential for optimal treatment and safety of patients. The increasing availability of biosimilars provides patients and doctors with less expensive alternatives and increases the accessibility of biologic therapy to needy patients. In this review, we discuss the concept of biosimilars, the need for appropriate regulatory pathways and their current status in dermatology.

Dehabilitation in the era of elimination and rehabilitation: a study of 100 leprosy patients from a tertiary care hospital in India.

OBJECTIVES: To study the clinical profile of leprosy patients; to assess dehabilitation in leprosy patients and to study the factors affecting dehabilitation. DESIGN: A cross-sectional questionnaire-based study was carried out on 100 leprosy patients visiting the All India Institute of Medical Sciences (AIIMS), New Delhi between February 2009 and February 2010. Demographic and clinical data were collected and subjects were administered the 52-item Anandaraj Dehabilitation scale which measures the negative impact of leprosy on family relationships, vocational condition, social interaction and self-esteem. RESULTS: The mean patient age was 30.9 years, 81% were males, 51% were at the lepromatous end of the spectrum, 87% had multibacillary leprosy, 22% each had Type 1 and Type 2 reactions, 22% had Grade 1 disability and 39% had Grade 2 disability. The mean duration of symptoms before diagnosis was 20 months. On the Anandaraj scale, 23% had high levels of dehabilitation; on an average, scores were in the range of medium level dehabilitation. Nearly 80% of patients avoided meeting friends, one-third hid the diagnosis from their families and worried about losing their jobs due to the disease, while around a quarter avoided sexual relations, used separate utensils and avoided touching children. Over 40% of unmarried patients faced matrimonial difficulty due to leprosy. Anxiety and guilt were common and incidence of suicidal ideas was much higher than the lifetime incidence in general population. Lack of education, Type 2 reactions, Grade 2 disability and lower age were predictors of greater dehabilitation. CONCLUSIONS: Dehabilitation of leprosy patients continues in this post-elimination era of rehabilitation. A large segment of preventable disability and resultant dehabilitation is likely being missed. There is an urgent need for corrective and preventive measures.

The psychosocial impact of vitiligo in Indian patients.

BACKGROUND: Vitiligo has a special significance in Indian patients both because depigmentation is obvious on darker skin and the enormous stigma associated with the disease in the culture. AIMS: This study was carried out to determine the beliefs about causation, aspects of the disease that cause concern, medical, and psychosocial needs of the patients, expectation from treatment and from the treating physician, and effects of disease on the patient's life. METHODS: Semi-structured interviews were conducted in 50 patients with vitiligo. Purposive sampling was used to select subjects for the study. Each interview was recorded on an audio-cassette and transcripts were analyzed to identify significant issues and concerns. RESULTS: Patients had a range of concerns regarding their disease such as physical appearance, progression of white patches onto exposed skin and the whole body, ostracism, social restriction, dietary restrictions, difficulty in getting jobs, and they considered it to be a significant barrier to getting married. The condition was perceived to be a serious illness. Stigma and suicidal ideation was reported. While there were several misconceptions about the cause of vitiligo, most patients did not think their disease was contagious, heritable or related to leprosy. Multiple medical consultations were frequent. Complete repigmentation was strongly desired, but a lesser degree of repigmentation was acceptable if progression of disease could be arrested. The problems were perceived to be more severe in women. The disease imposed a significant financial burden. CONCLUSION: Addressing psychosocial factors is an important aspect of the management of vitiligo, particularly in patients from communities where the disease is greatly stigmatizing.

Photosensitive spongiotic/lichenoid eruption of micropapules and plaques: a morphologically distinct entity.

BACKGROUND: A distinct morphological pattern of photodermatosis has been observed with shiny skin colored to hypopigmented tiny papules, discrete or coalescing to form plaques. AIMS: To study the clinico-pathological features of patients presenting with these lesions. METHODS: A total of 72 patients were recruited. Clinical examination and skin biopsy was carried out to evaluate the morphological patterns and the histopathological features. RESULTS: In all patients, tiny discrete to coalescent papules were observed on sun-exposed sites but usually sparing the face. The condition occurred more commonly in women. Three specific histopathological patterns were observed : spongiotic (43.7%), lichenoid (22.5%), psoriasiform (18.7%) and also perivascular pattern in 5%. CONCLUSION: Photosensitive lichenoid eruption is a morphologically distinct photodermatoses that is commonly seen in Indian patients with pathological features showing mostly spongiotic changes and in some cases lichenoid changes.

Bowen's disease on finger: a diagnostic and therapeutic challenge.

Bowen's disease commonly presents as a solitary asymptomatic plaque involving head and neck region or lower limbs. We present a case of a sixty seven-year-old man with an itchy, oozy, crusted solitary plaque on the right ring finger of eighteen months duration with histopathology consistent with Bowen's disease. The lesion was initially treated with topical 5% imiquimod but due to relapse and inadequate response to a second course, complete surgical excision followed by full thickness skin grafting was done. Recurrence after about 6 months in the form of a small papule adjacent to the initial site was also treated with excision. This report highlights the potential of Bowen's disease to mimic more common dermatoses and a high index of suspicion, supported by histopathology, is required to diagnose and treat it without delay, which in turn may require a multimodality approach. We also reviewed the current literature on the same.

A descriptive study to characterize segmental vitiligo.

BACKGROUND: Segmental vitiligo is a small but unique subset of vitiligo requiring due importance due to its lack of response to medical treatment but excellent response to surgical treatment. Characterization of the pattern of segmental vitiligo will also help to understand the pathogenesis of the disease. AIM: To characterize clinically the features of segmental vitiligo, a cross-sectional clinical study at dermatology outpatient department at AIIMS was carried out. METHODS: Consecutive 188 patients were evaluated to characterize the clinical features of segmental vitiligo by detailed history, clinical examination, and photography. Frequency of each clinical feature was calculated. RESULTS: Certain features such as early onset, initial progression of disease followed by stability, blaschkoid pattern, irregular margins, leucotrichia within and beyond the vitiligo lesion, and islands of pigmented macules within the vitiligo lesion were found to be characteristic of the disease. CONCLUSIONS: A combination of various features such as early onset of disease, blaschkoid pattern, irregular margins, leucotrichia, and islands of pigmented macules within the vitiligo lesion are helpful in diagnosis of the disease.

Segmental vitiligo: a randomized controlled trial to evaluate efficacy and safety of 0.1% tacrolimus ointment vs 0.05% fluticasone propionate cream.

BACKGROUND: Segmental vitiligo is a small subset of vitiligo which responds very well to surgical therapy, but the role of medical treatment is not very well defined. AIM: To compare the efficacy and safety of 0.1% tacrolimus ointment versus 0.05% fluticasone propionate cream in patients of segmental vitiligo. METHODS: A randomized control trial was conducted in a tertiary care hospital on 60 consecutive patients with segmental vitiligo. Patients with segmental vitiligo exclusively or along with focal vitiligo, untreated or had not taken any topical treatment in previous 1 month or systemic treatment in previous 2 months, from May 2005 to January 2007, were block randomized into two groups. Children <5 years, pregnant and lactating women, and patients with known hypersensitivity to either drug and with associated multiple lesions of vitiligo were excluded. Group A (n = 29) patients were treated with tacrolimus 0.1% ointment twice daily and group B (n = 31) patients were treated with 0.05% of fluticasone cream once daily for 6 months. Response and side effects were recorded clinically and by photographic comparison. RESULTS: Nineteen patients treated with tacrolimus and 21 patients treated with fluticasone completed the treatment with median repigmentation of 15% and 5%, respectively, at 6 months (P = 0.38). Transient side effects limited to the application site were observed. CONCLUSIONS: Both tacrolimus and fluticasone propionate produce variable but overall unsatisfactory repigmentation in segmental vitiligo.

Profile of systemic sclerosis in a tertiary care center in North India.

AIM: To study the clinical and immunological profile in patients of systemic sclerosis from North India and compare it with other ethnic groups. METHODS: Patients presenting to us between the years 2001 and 2004 and fulfilling the American Rheumatism Association (ARA) criteria for systemic sclerosis were included. There were 84 females and 16 males with the mean age of 32.5 +/-11.62 years and a mean duration of 6.49 +/- 4.34 years. All patients were admitted to the dermatology ward for detailed history and examination including Rodnan score. Investigations including hemogram, hepatic and renal functions, serum electrolytes, urine for albumin, sugar, microscopy and 24h urinary protein estimation, antinuclear antibody, chest X-ray, barium swallow, pulmonary function test, electrocardiogram and skin biopsy were done. RESULTS: The most common presenting symptoms were skin binding-down (98.5%), Raynaud's phenomenon 92.9%, pigmentary changes 91%, contracture of fingers 64.6%, fingertip ulcer 58.6%, restriction of mouth opening 55.5%, dyspnea 51.1%, joint complaints 36.7% and dysphagia in 35.2%. The mean Rodnan score was 25.81 +/- 10.04 and the mean mouth opening was 24.6 +/- 19.01 mm. The laboratory abnormalities included raised ESR in 87.8%, ANA positive in 89.1%, proteinuria in 6.0%, abnormal chest X-ray in 65.3%, abnormal barium swallow in 70.2% and reduced pulmonary function test in 85.8%. CONCLUSION: The clinical and immunological profile of systemic sclerosis in North India is similar to that of other ethnic groups except that pigmentary changes are commoner and renal involvement is relatively uncommon.

Superficial basal cell carcinoma on face treated with 5% imiquimod cream.

Imiquimod, an immune response modifier, is known to possess both anti-viral and anti-tumor effect. We report our experience of treating a large superficial spreading basal cell carcinoma with 5% imiquimod cream. A 65-year-old male had an asymptomatic, hyperpigmented, slowly progressive, indurated, 3 x 4 cm plaque on the left cheek for two months. Biopsy from the lesion showed features of basal cell carcinoma. The patient was treated with imiquimod 5% cream, topically three times a week for six months with complete resolution of the lesion and without any side-effects. There was no clinical or histological recurrence after three months of stopping the treatment.

Extensive alopecia areata treated with betamethasone oral mini-pulse therapy: an open uncontrolled study.

BACKGROUND: Extensive alopecia areata is known to respond to daily oral corticosteroids. To minimize the side effects of daily corticosteroids, oral mini-pulse therapy with betamethasone has been used in vitiligo and other dermatoses. There are a few studies in alopecia areata also. AIM: To evaluate the efficacy of oral mini-pulse therapy in extensive alopecia areata. METHODS: It is an open study on sixteen adolescents and adults with alopecia areata/ totalis/universalis treated with oral mini-pulse therapy for a minimum period of six months. The patients were evaluated clinically and with serial photographs for response and periodical investigations were undertaken to look for the side effects. All the patients were followed up for 5-8 months to look for any relapse. RESULTS: Seven (43.7%) patients showed an excellent response and five (31.2%) patients had good response. Two patients (12.5%) had unsatisfactory response and another two (12.5%) were non-responders. There were insignificant/minimal side effects. CONCLUSION: Oral mini-pulse therapy with betamethasone is a safe and effective therapeutic modality for extensive alopecia areata.