Impact of COVID-19 Pandemic on Dermatology Teaching Program in India: A Survey on the Faculty and Residents' Perspective.

Background: Impact of COVID-19 pandemic has been immense. An innocent casualty of this disaster is medical education and training. Dermatology, which primarily deals with out-patient services, medical and surgical interventions, and in-patient services, was one of the worst hit. The National Medical Commission of India has implemented competency-based medical education (CBME) in Dermatology, Venereology, and Leprosy since 2019. The new curriculum relies on acquiring practical and procedural skills, training skills in research methodology, professionalism, attitude, and communication. Objectives: The study was undertaken to understand the implications of the COVID-19 pandemic on postgraduate dermatology CBME training in India. Materials and Methods: A questionnaire-based survey was carried out on postgraduate dermatology teachers and residents in India after obtaining ethics committee approval. An online semi-structured English questionnaire was administered by Google Forms. The calculated sample size was 366 dermatology faculty and 341 postgraduate students. Validity (Content validity ratio (CVR) ≥0.56) and reliability (Cronbach's alpha coefficient 0.7249) of the questionnaire were determined. Results: Among the 764 responses received, 51.4% reported that their institutes were converted to exclusive COVID hospitals. Domains of dermatology education affected were procedural training (n = 655), bedside clinical teaching (n = 613), outpatient department-based clinical teaching (n = 487), bedside laboratory procedures (n = 463), research activities (n = 453), histopathology (n = 412), and theory classes (n = 302). To keep up with the teaching-learning process, online platforms were mostly utilized: Zoom Meeting (n = 379), Google Meet (n = 287), and WhatsApp Interaction (n = 224). Teaching during ward rounds was significantly more affected in exclusively COVID institutes than non-exclusive COVID institutes (P < 0.001). Psychomotor skill development suffered a major jolt with 26.7% of respondents reporting a standstill (P < 0.001). Communication skills among students suffered due to social distancing, mask, and poor attendance of patients. According to 23.84% of respondents, formative assessment was discontinued. Conclusion: Online seminars, journal clubs, and assessments have been incorporated during the pandemic. Online modalities should be used as a supplementary method as psychomotor skills, communication skills, research work, and bedside clinics may not be replaced by the e-learning.

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.

Nail dermoscopy (onychoscopy) findings in the diagnosis of primary onychomycosis: A cross-sectional study.

BACKGROUND: Diagnosis of onychomycosis involves direct microscopic examination with potassium hydroxide, culture or histopathology with periodic acid-Schiff staining. Nail dermoscopy (onychoscopy) is a noninvasive, rapid and easily available diagnostic tool though its utility in onychomycosis remains unexplored. OBJECTIVE: To describe the various onychoscopic patterns and compare its percentage positivity with that of standard potassium hydroxide examination, culture and histopathology in patients with a clinical diagnosis of onychomycosis. METHODS: The study recruited 100 patients with a presumptive clinical diagnosis of onychomycosis. A detailed history, physical examination including that of nails and clinical photography was followed by onychoscopy with DermLite DL3. The nail clippings were sent for direct microscopic examination with potassium hydroxide, mycological culture and histopathology with periodic acid-Schiff stain. The patient was said to have onychomycosis if at least one of the three tests was positive. RESULTS: Onychomycosis was confirmed by potassium hydroxide and/or culture and/or histopathology in 88 patients. Onychoscopic features were identified and their association with different clinical variants of onychomycosis was attempted. Percentage positivity for diagnosing onychomycosis in decreasing order was: direct microscopic examination with potassium hydroxide followed by spiked pattern, subungual hyperkeratosis, distal irregular termination on onychoscopy, histopathology, mycological culture and ruins aspect again observed on onychoscopy. LIMITATIONS: Small sample size. CONCLUSIONS: Many onychoscopic features are highly specific for different variants of onychomycosis so onychoscopy may serve as an important and quick adjunct to diagnose onychomycosis until other time-consuming investigations, such as culture and periodic acid-Schiff become available. Studies on a larger population will help arrive at a logistic conclusion.

Evaluation of cervical and anal intraepithelial neoplasia in women attending a sexually transmitted infection clinic.

BACKGROUND: The incidence of anal and cervical cancers and their precursors have increased in the past decades. Women with HIV and sexually transmitted infections are at a higher risk. Cervical human papilloma virus infection may serve as a reservoir and source of anal infection or vice versa. A higher incidence of anal cytological abnormality has been observed in patients with abnormal cervical cytology. OBJECTIVES: This cross sectional study was designed to estimate the prevalence and associations of anal and cervical cytological abnormalities in a cohort of sexually active women using Papanicolaou smears. METHODS: We conducted a single centre study of 35 consecutive HIV positive and 40 HIV negative women attending the sexually transmitted infection clinic. Cervical and anal specimens were obtained for cytology after a detailed history and examination. Chi square test and coefficient of correlation were used for comparison. RESULTS: Cervical dysplasia was observed in 22.6% (17.3% low-grade squamous intraepithelial lesion and 5.3% high grade squamous intraepithelial lesion) and anal dysplasia in 8% study subjects (6.7% low-grade squamous intraepithelial lesion and 1.3% high grade squamous intraepithelial lesion); no association was observed with HIV infection. A higher number of patients with cervical dysplasia (29.4%) were found to have concomitant anal dysplasia (P = 0.002). History of anal intercourse was reported in all patients with anal dysplasia and was higher (P < 0.037) in patients with cervical dysplasia. LIMITATIONS: The limitations included a small sample size, lack of correlation with histological findings and bias due to STI clinic-based recruitment of the study population. CONCLUSION: Cytology may be used to screen for cervical and anal dysplasia in women irrespective of HIV status. Women with cervical dysplasia may be preferentially screened for anal dysplasia and vice versa. Anal intercourse may be a risk factor for anal and cervical dysplasia.

Comparative efficacy of continuous and pulse dose terbinafine regimes in toenail dermatophytosis: A randomized double-blind trial.

INTRODUCTION: Dermatophytes are the most frequently implicated agents in toenail onychomycosis and oral terbinafine has shown the best cure rates in this condition. The pharmacokinetics of terbinafine favors its efficacy in pulse dosing. OBJECTIVES: To compare the efficacy of terbinafine in continuous and pulse dosing schedules in the treatment of toenail dermatophytosis. METHODS: Seventy-six patients of potassium hydroxide (KOH) and culture positive dermatophyte toenail onychomycosis were randomly allocated to two treatment groups receiving either continuous terbinafine 250 mg daily for 12 weeks or 3 pulses of terbinafine (each of 500 mg daily for a week) repeated every 4 weeks. Patients were followed up at 4, 8 and 12 weeks during treatment and post-treatment at 24 weeks. At each visit, a KOH mount and culture were performed. In each patient, improvement in a target nail was assessed using a clinical score; total scores for all nails and global assessments by physician and patient were also recorded. Mycological, clinical and complete cure rates, clinical effectivity and treatment failure rates were then compared. RESULTS: The declines in target nail and total scores from baseline were significant at each follow-up visit in both the treatment groups. However, the inter-group difference was statistically insignificant. The same was true for global assessment indices, clinical effectivity as well as clinical, mycological, and complete cure rates. LIMITATIONS: The short follow-up in our study may have led to lower cure rates being recorded. CONCLUSION: Terbinafine in pulse dosing is as effective as continuous dosing in the treatment of dermatophyte toenail onychomycosis.

Evaluation of apoptosis in skin biopsies of patients of borderline leprosy and lepra type 1 reaction.

BACKGROUND: The role of apoptosis is not clear in leprosy and lepra reactions. OBJECTIVES: To evaluate frequency of apoptosis in skin lesions of borderline leprosy and Type 1 lepra reaction. METHODS: Sixty patients with borderline leprosy (30 with clinically diagnosed Type 1 reaction (T1R) (Group I) and 30 without clinical evidence of reaction (Group II)) were analyzed in this prospective study. Apoptosis was detected by two different methods for comparison, that is, histopathologic examination (HPE) and deoxyribonucleic acid (DNA) fragmentation and electrophoresis. Quantification of apoptotic bodies/10 high power fields (HPF) was also done. RESULTS: Out of 30 cases, apoptosis was detected in 29 cases in Group I and 24 cases in Group II by HPE (P = 0.103), whereas, with the use of DNA electrophoresis it was detected in 24 cases in Group I and 18 cases in Group II (P = 0.091). On quantitative estimation it was found that number of apoptotic bodies are higher in Group I in comparison to Group II (2.77 vs 1.99), which is statistically significant. CONCLUSIONS: There was moderate agreement (κ = 0.47) between the two methods of apoptosis detection. Apoptosis was seen more in patients with T1R both qualitatively (statistically nonsignificant) and quantitatively (statistically significant). Clinical significance of this novel finding is that apoptosis can be used as one of the variables for diagnosis of T1R to increase detection rate.

Mucocutaneous leishmaniasis caused by Leishmania donovani infection in an Indian man.

BACKGROUND: Leishmaniasis is a protozoal disease caused by species of Leishmania. Mucocutaneous leishmaniasis (MCL) involves the skin and mucosa. India is endemic for species such as Leishmania donovani and Leishmania major, which are responsible for visceral and cutaneous leishmaniasis, respectively. Although MCL has been reported from India previously, the implicated pathogen was identified as L. donovani in only one case. CASE REPORT: A 55-year-old man presented with a nasal ulcer of four years' duration. He had been treated for borderline lepromatous (BL) leprosy 25 years earlier. Differential diagnoses of MCL, lupus vulgaris, and subcutaneous mycosis were considered. Leishman-Donovan bodies were seen on tissue imprints, and histopathology showed epidermal thinning with loss of appendages and dense pandermal infiltrate. Polymerase chain reaction was positive for L. donovani-specific DNA amplification. A diagnosis of MCL with treated BL leprosy was made. The patient was treated with sodium stibogluconate and achieved complete healing of the ulcer. CONCLUSIONS: The coexistence of manifestations of disease from opposite ends of the spectrum (a hyperergic form of leishmaniasis with an anergic form of leprosy) is difficult to explain. However, the development of MCL after the cure of BL leprosy may reflect the loss of the inhibitory effect of Mycobacterium leprae antigen on interferon-γ production, and delayed persistence and the gradual clearance of the antigen from the body may account for the 20-year time lag. Further research centered on the immunological interactions between leishmaniasis and leprosy is warranted, particularly with respect to different Leishmania species.

Evaluation of key histologic variables in skin biopsies of patients of borderline leprosy with type 1 lepra reaction.

BACKGROUND: Leprosy remains an important health problem mainly in the African and South-East Asia regions. Type 1 reaction is an immune-mediated phenomenon known to complicate at least 30% of patients of leprosy. Diagnosing type 1 reaction correctly is important for timely institution of therapy to prevent and treat neuropathy-associated disability and morbidity. There is paucity of literature on definitive criteria for histologic diagnosis of type 1 reaction. This study was conducted to determine the key histologic variables for diagnosing type 1 reaction. METHODS: This was a prospective study recruiting 104 patients with borderline leprosy. Three pathologists blinded to the clinical diagnosis independently assessed the cases. The agreement between each histological variable and clinical diagnosis was then calculated by using Cohen's kappa (Κ) coefficient. RESULTS: Histological diagnosis of type 1 reaction was given to 27 (67.5%) of 40 clinically diagnosed cases of type 1 reaction cases. Histological variables chosen as key variables for histological diagnosis of type 1 reaction were presence of giant cells, dermal edema, intragranuloma edema, granuloma fraction 31-50%, and presence of medium to large giant cells. CONCLUSION: This study has shown that T1R are still underdiagnosed histologically in comparison with clinical assessments. The key variables for diagnosing type 1 reaction were proposed.

The efficacy of azithromycin in pityriasis rosea: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Macrolides are prescribed in the treatment of pityriasis rosea despite conflicting results of the limited number of studies evaluating their role in its treatment. AIM: A randomized double-blind placebo-controlled trial was conducted to evaluate the effect of azithromycin on the clinical course of pityriasis rosea. METHODS: Seventy patients of pityriasis rosea were given either azithromycin (n=35) or placebo (n=35) and were followed-up at 2, 4 and 6 weeks. Pruritus was assessed in both groups using the visual analogue scale (VAS) . Change in the pityriasis rosea severity score (PRSS) and in the VAS were recorded as outcome measures and were compared statistically. RESULTS: The decrease in PRSS from baseline through 2, 4 and 6 weeks within both treatment (P<0.001) and placebo (P<0.001) arms was found to be statistically significant; however, this change was not significantly different in the two groups (P=0.179). Similarly, the decrease in VAS was found to be statistically significant within both groups (P<0.001); however, the change was comparable between the two groups (P<0.937). Analysis by Fisher's exact test did not find a significant difference between the two groups for PRSS and VAS. CONCLUSION: Azithromycin is not effective in pityriasis rosea and the use of macrolides for this disease should not be encouraged in clinical practice.

New insights in the pathogenesis of type 1 and type 2 lepra reaction.

In the current scenario of leprosy elimination, lepra reactions (LRs) remain a major persistent problem. Type 1 LR (T1LR) and type 2 LR (T2LR) are the major causes of nerve damage and permanent disabilities. The immunopathogenesis of LR have recently become an important field of research, since it may provide the relevant targets for the early detection and control of these episodes. Presently, there are no uniformly acceptable laboratory markers for LR. Genetic and serum markers in human host may predict susceptibility to reactions as well as progression of nerve damage in leprosy. Therefore, a deeper understanding of the molecular mechanisms involved in LR may provide a rational strategy for early diagnosis and prevention of the catastrophic consequences of LR.

Premature graying of hair.

Premature graying is an important cause of low self-esteem, often interfering with socio-cultural adjustment. The onset and progression of graying or canities correlate very closely with chronological aging, and occur in varying degrees in all individuals eventually, regardless of gender or race. Premature canities may occur alone as an autosomal dominant condition or in association with various autoimmune or premature aging syndromes. It needs to be differentiated from various genetic hypomelanotic hair disorders. Reduction in melanogenically active melanocytes in the hair bulb of gray anagen hair follicles with resultant pigment loss is central to the pathogenesis of graying. Defective melanosomal transfers to cortical keratinocytes and melanin incontinence due to melanocyte degeneration are also believed to contribute to this. The white color of canities is an optical effect; the reflection of incident light masks the intrinsic pale yellow color of hair keratin. Full range of color from normal to white can be seen both along individual hair and from hair to hair, and admixture of pigmented and white hair is believed to give the appearance of gray. Graying of hair is usually progressive and permanent, but there are occasional reports of spontaneous repigmentation of gray hair. Studies evaluating the association of canities with osteopenia and cardiovascular disease have revealed mixed results. Despite the extensive molecular research being carried out to understand the pathogenesis of canities, there is paucity of effective evidence-based treatment options. Reports of repigmentation of previously white hair following certain inflammatory processes and use of drugs have suggested the possibility of cytokine-induced recruitment of outer sheath melanocytes to the hair bulb and rekindled the hope for finding an effective drug for treatment of premature canities. In the end, camouflage techniques using hair colorants are outlined.