Profile of dermatology inpatients and admissions over a four year period in a tertiary level government teaching hospital in North India.

BACKGROUND: Although dermatology is mostly an outpatient specialty, some patients with severe skin disease need hospital admission for management. There is a paucity of data regarding the profile of these dermatology in-patient admissions. AIMS: We studied the profile of patients admitted to the dermatology ward of our tertiary care government hospital in North India. METHODS: This was a retrospective analysis of discharge sheets of patients admitted in the dermatology ward from January 1, 2014 to December 31, 2017. RESULTS: Discharge sheets of 2032 admissions for 1664 patients were analyzed. The most common diagnoses in the admitted patients were immunobullous disorders (576, 28%), connective tissue diseases (409, 20%), infections, including leprosy and sexually transmitted infections (179, 8.8%), psoriasis (153, 7.5%) and reactive arthritis (92, 4.5%). The mean duration of admission was 13.95±11.67 days (range 1-118 days). Two hundred and fifty-six patients (15.38%) were re-admitted, accounting for 368 (18.11%) re-admissions. Patients with immunobullous disorders (OR 1.72, 95% CI 1.29-2.28) and psoriasis (OR 1.62, 95% CI 1.02-2.55) were more likely to be re-admitted. Adult patients, those who were admitted for more than four weeks, those who had comorbidities, and those who developed a complication during the hospital stay also had a greater likelihood of being re-admitted. LIMITATIONS: The retrospective design of the study, and the non-availability of data regarding transfers to other specialties or intensive care units and deaths were the main limitations of this study. CONCLUSION: This study describes the profile of patients admitted in a dermatology ward of a tertiary care centre center in North India. The patient profile and admission characteristics associated with a higher probability of re-admission were identified.

Psychosocial burden of lichen planus pigmentosus is similar to vitiligo, but greater than melasma: A cross-sectional study from a tertiary-care center in north India.

BACKGROUND: Lichen planus pigmentosus can have a negative impact on the quality of life; however, this has not been studied in detail. OBJECTIVES: To study the quality of life in patients with lichen planus pigmentosus and compare it with patients with vitiligo and melasma. METHODS: This was a cross-sectional study conducted in a tertiary-care center in north India from January 2018 to May 2019. Patients ≥ 18 years of age with lichen planus pigmentosus (n = 125), vitiligo (n = 113) and melasma (n = 121) completed the Dermatology Life Quality Index (DLQI) questionnaire and answered a global question on the effect of disease on their lives. In addition, patients with vitiligo completed the Vitiligo Impact Scale (VIS)-22 questionnaire, while those with lichen planus pigmentosus and melasma filled a modified version of VIS-22. RESULTS: The mean DLQI scores in patients with lichen planus pigmentosus, vitiligo and melasma were 10.9 ± 5.95, 9.73 ± 6.51 and 8.39 ± 5.92, respectively, the difference being statistically significant only between lichen planus pigmentosus and melasma (P < 0.001). The corresponding mean modified VIS-22/VIS-22 scores were 26.82 ± 11.89, 25.82 ± 14.03 and 18.87 ± 11.84, respectively. This difference was statistically significant between lichen planus pigmentosus and melasma, and between vitiligo and melasma (P < 0.001 for both). As compared to vitiligo, patients with lichen planus pigmentosus had a significantly greater impact on "symptoms and feelings" domain (P < 0.001) on DLQI, and on "social interactions" (P = 0.02) and "depression" (P = 0.04) domains on VIS-22. As compared to melasma, patients with lichen planus pigmentosus had significantly higher scores for "symptoms and feelings," "daily activities," "leisure" and "work and school" domains of DLQI, and all domains of VIS-22. Female gender was more associated with impairment in quality of life in patients with lichen planus pigmentosus, while lower education, marriage, younger age and increasing disease duration showed a directional trend. LIMITATIONS: Use of DLQI and modified version of VIS-22 scales in the absence of a pigmentary disease-specific quality-of-life instrument. CONCLUSION: Patients with lichen planus pigmentosus have a significantly impaired quality of life. The psychosocial burden of lichen planus pigmentosus is quantitatively similar to that of vitiligo, but significantly greater than melasma.

A retrospective case series of 12 patients with chronic reactive arthritis with emphasis on treatment outcome with biologics.

BACKGROUND: Patients with reactive arthritis frequently present to dermatologists. However, there is paucity of information regarding its clinical aspects and management in dermatological literature. OBJECTIVE: To review the clinical features and management of patients with chronic reactive arthritis admitted to the dermatology department of a teaching hospital. METHODS: This was a retrospective analysis of patients with reactive arthritis admitted to the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India from January 2016 to February 2018. RESULTS: There were 12 males (disease duration 9-180 months). Biologics were used in 9 (75%) patients on 16 different occasions, the most frequent being infliximab (n = 10 times), followed by adalimumab (n = 3), etanercept, secukinumab and itolizumab (n = 1 each), in combination with other systemic agents. Response rate with treatment regimens including biologics (69% responders, 31% partial responders) was statistically significantly better than those without biologics (27% responders, 46% partial responders, 27% nonresponders; P = 0.036), using a composite measure assessing improvement in skin and joint symptoms. Biologics were discontinued on 50% of the occasions, after a median of 3.5 months (range 1.5-7.5 months) because of satisfactory response (n = 4), therapeutic fatigue (n = 3) or adverse event (n = 1). After biologic discontinuation, the response was sustained for a median of 5 months (range 3-6 months) before disease exacerbation. The number of treatment switches increased with the follow-up duration (median three switches per patient, range 1-8). The median follow-up duration was 10.5 months (range 4-76 months). CONCLUSION: Biologics produce rapid improvement in skin and joint symptoms in chronic reactive arthritis, but the response is not long-lasting. Patients with chronic reactive arthritis have a waxing and waning course despite regular treatment. LIMITATIONS: The limitations are retrospective design, small sample size and lack of a validated outcome measure.

Dermoscopy and patch testing in patients with lichen planus pigmentosus on face: A cross-sectional observational study in fifty Indian patients.

BACKGROUND: Lichen planus pigmentosus (LPP) is a common cause of facial melanosis in the dark-skinned population. At present, information on dermoscopy and patch testing in LPP is limited. OBJECTIVES: To describe dermoscopic findings and study the role of patch testing in patients with LPP on the face. METHODS: Facial lesions of 50 patients with LPP were studied dermoscopically, followed by histological evaluation. Patch and photopatch tests with the Indian Standard Series and Scandinavian series, respectively, and patient's own cosmetics were performed on all patients. RESULTS: The most common dermoscopic finding was dots and/or globules (43/50, 86%) in different patterns: hem-like (20.9%), arcuate (18.6%), incomplete reticular (39.5%), complete reticular (7%), and not otherwise specified (14%). Other patterns were exaggerated pseudoreticular pattern, accentuation of pigmentation around follicular openings, targetoid appearance, and obliteration of the pigmentary network. There were 26 relevant patch tests in 17 (34%) patients: para-phenylenediamine (n = 5), nickel (n = 3), colophony, perfume mix and fragrance mix (n = 2 each), thiuram mix and 3,3,4,5-tetrachlorosalicylanilide (n = 1 each), and patients' own products (n = 9). The only positive photopatch test was to fentichlor. No clinical or histological finding differed significantly based on patch test results. The only dermoscopic finding to be statistically associated with a positive patch test was the non-characteristic arrangement of dots/globules (P = 0.042). LIMITATIONS: Dermoscopic features were not correlated with clinical features or disease duration. Implications of patch testing on the management of LPP cannot be commented upon as ours was a cross-sectional study. CONCLUSIONS: The present study describes the dermoscopic findings of facial lesions in LPP. Our patch test results suggest a probable role of allergens in causing LPP on the face.

Urocytological evaluation of pemphigus patients on long term cyclophosphamide therapy: A cross sectional study.

BACKGROUND: Cyclophosphamide therapy is associated with several urological complications including urinary bladder malignancy. Data on urologic complications of chronic cyclophosphamide therapy for dermatologic conditions is not available. OBJECTIVES: To study the urocytological profile of pemphigus patients on long-term cyclophosphamide therapy. MATERIALS AND METHODS: In a cross-sectional study, consecutive patients who had received cyclophosphamide therapy for pemphigus for more than 12 months were included. All patients were subjected to urinalysis including microscopy, culture, and urine cytology. Immunocytochemical staining for cytokeratin 20 (CK-20) on urine sediments and ELISA (enzyme-linked immunosorbent assay) for nuclear membrane protein-22 (NMP-22) were performed in all cases. In patients with urinary symptoms, microscopic hematuria, or those detected with abnormal urine sediment cytology, NMP-22, and CK-20 positivity, cystoscopy, and other relevant investigations were also done. RESULTS: A total of 44 patients (43 of pemphigus vulgaris and one of pemphigus foliaceus) were recruited. Mean duration of cyclophosphamide intake was 2.9 ± 1.7 years (range 1-8 years) with a mean cumulative dose of 53 ± 28.4 g (range 6.5-141 g). Twenty-one cases (47.7%) each were asymptomatic and symptomatic with episodic urinary symptoms [of which two had urinary tract infection (UTI)] and two patients had gross hematuria. Urine cytology revealed mild urothelial nucleomegaly with hyperchromasia in four patients. However, CK-20 and NMP-22 were negative in all samples. Cystoscopy was performed in 21 cases and did not reveal any sign of bladder malignancy. LIMITATIONS: A relatively small sample size and lack of long-term follow-up were limitations. CONCLUSIONS: In our study, no serious urologic complications were found in pemphigus cases on chronic cyclophosphamide therapy.

Occupational dermatoses: An Asian perspective.

Occupational dermatoses contribute to a significant portion of work-related diseases, especially in Asia, where a major portion of the workforce is in the unorganized sector. This review article is focussed on the frequency and pattern of occupational skin diseases reported across Asian countries and type of allergens implicated in different occupations. The literature was searched systematically using key words 'occupational dermatoses,' 'occupational skin disease' and name of each Asian country. Ninty five full-text articles were considered relevant and evaluated. Some of the dermatoses seen in industrial workers in Asian countries are similar to those in Western countries, including dermatoses due to chromate in construction and electroplating workers, epoxy resin, and chromate in painters, wood dust in workers in the furniture industry, azo dyes in textile workers and formaldehyde and chromates in those working in the leather and dyeing industries, dermatoses in domestic workers, chefs and health-care workers. Dermatoses in workers engaged in agriculture, beedi (tiny cigars) manufacture, agarbatti (incense sticks) production, fish processing, carpet weaving, sanitation and those working in coffee plantations and coal mines appear to be unique to Asian countries. Recognition of clinical patterns and geographic variations in occupational skin diseases will provide an impetus to further strengthen future research in these areas, as well as improving their management.

Clinical efficacy of rituximab in the treatment of pemphigus: A retrospective study.

BACKGROUND: Pulsed corticosteroids have been used successfully for the management of pemphigus. However, prolonged use of glucocorticoids may be associated with adverse effects and some patients show a poor response to conventional therapy. Biologics have shown a promising role in such cases; however, there is limited data from the Indian subcontinent. OBJECTIVE: The primary objective was to assess the efficacy and adverse effects of rituximab in pemphigus. The secondary objective was to measure the cumulative doses of corticosteroids required for these patients. METHODS: We undertook a retrospective review of records of 25 pemphigus patients (pemphigus vulgaris: 21, pemphigus foliaceus: 4) who had received rituximab infusion (rheumatoid arthritis protocol in 21 patients, modified in 4). Oral prednisolone was administered in dosages up to 0.5 mg/kg of body weight and tapered over the next 3-4 months according to the disease activity. However, other immunosuppressive agents such as cyclophosphamide and azathioprine were continued for one year after clinical remission was achieved. RESULTS: Complete remission was observed in 22 (88%) patients. The mean time to disease control and complete remission was 1.10 and 4.36 months, respectively. Four (16%) patients experienced relapse after a mean duration of 11.75 months. The mean total dose of oral steroids administered was equivalent to 3535.64 mg of prednisolone. Exacerbation of disease was noted in two patients after the first dose of rituximab and infectious complications, pneumonia and cellulitis, developed in one patient each. LIMITATIONS: A small sample size, the retrospective nature of the study and unavailability of follow-up anti-desmoglein autoantibodies levels were limitations. CONCLUSION: Rituximab is an effective agent in the treatment of pemphigus. The use of rituximab enabled use of a lower initial dose of oral prednisolone in pemphigus and hence reduced its total cumulative dose. Severe side effects were rare.

Relevance of trichoscopy in the differential diagnosis of alopecia: A cross-sectional study from North India.

BACKGROUND: Trichoscopy is an office tool used in the diagnosis of alopecia but its utility has not been assessed. OBJECTIVES: To compare the trichoscopic characteristics of different types of alopecia, identify features of diagnostic value, and to determine the utility of trichoscopy in the diagnosis of alopecia. METHODS: A descriptive cross-sectional study was performed in patients with alopecia. After clinical assessment and relevant investigations, trichoscopy was performed using a non-polarized trichoscope (×10). The utility of trichoscopy in difficult cases of alopecia was assessed statistically. RESULTS: One hundred and twenty patients of alopecia (90 non-cicatricial, 30 cicatricial) were recruited. The diagnosis was made on the basis of a detailed history and clinical examination, and confirmed by biopsy and relevant investigations in difficult cases. Yellow dots (63.3%) were the most common trichoscopic feature followed by thin hair (40.8%). Among the 21 difficult cases of alopecia, trichoscopy was diagnostic in 19 (90.5%). Statistically significant features on intergroup comparison included black dots (Fischer's exact test, P< 0.001), cadaverized hair (P = 0.024), exclamation mark hair (P < 0.001) in alopecia areata; diameter diversity more than 20% (P < 0.001) and thin hair (P < 0.001) in androgenetic alopecia; broken hair of different lengths (P < 0.001), frayed hair (P < 0.001), split ends (P < 0.001) in trichotillomania; comma hair (P < 0.001) in tinea capitis and arborizing blood vessels in discoid lupus erythematosus (P = 0.012). LIMITATIONS: The small number of patients in some types of alopecia was a limiting factor. CONCLUSIONS: Trichoscopy is useful in the differential diagnosis of alopecia. Among the various trichoscopic findings, those of diagnostic value were identified.

A pilot study for diagnosis of genital Chlamydia trachomatis infections by polymerase chain reaction among symptomatic Indian women.

BACKGROUND: Chlamydia trachomatis is the most common bacterial etiology of sexually transmitted infection. AIM: A pilot study was designed using PCR for amplification and detection of a specific 517 bp sequence of the common endogenous plasmid of C. trachomatis from clinical swab specimens obtained from symptomatic female patients attending STD clinics of AIIMS and Regional STD Teaching, Training & Research Center, Safdarjang Hospital, New Delhi. METHODS: 97 patients were recruited in the study, and endocervical swabs were collected following standard procedures. The samples were analyzed by PCR and direct fluorescence antibody (DFA) for detection of C. trachomatis, and the sensitivity, specificity, PPV and NPV of PCR were calculated taking DFA as gold standard. RESULTS: Out of 97 samples tested, 9 were positive for C. trachomatis by PCR. 1 PCR positive patient was negative by DFA although a total of 11 patients were positive by DFA. The sensitivity, specificity, PPV and NPV of PCR with reference to DFA was 72.73%, 98.84%, 88.89% and 96.59%, respectively. This PCR had high specificity and NPV for detection of C.trachomatis. CONCLUSIONS: In light of the introduction of enhanced syndromic approach, which involves the use of laboratory techniques (wherever possible) to confirm clinical diagnosis, a diagnostic PCR with high specificity and NPV is particularly valuable for determination of etiological diagnosis and hence contribute to judicious use of antimicrobials in the community.

Hydroxyurea as an alternative therapy for psoriasis.

BACKGROUND: Methotrexate is the drug of choice in extensive psoriasis in developing countries. In patients who can not take methotrexate either due to intolerance or concomitant liver disease, there is an urgent need for an alternative affordable and accessible drug. AIMS: To evaluate the therapeutic efficacy and safety of hydroxyurea as an alternative in the management of patients with extensive psoriasis. METHODS: A prospective study was carried out over 16 months on 34 patients with chronic plaque psoriasis (>20% body surface area involvement), erythrodermic or generalized pustular psoriasis who were partially responsive or non-responsive to the conventional topical and systemic modalities of therapy. Besides doing a baseline hemogram, liver and renal function tests, and urine analysis, these tests were frequently repeated during the course of therapy. Hydroxyurea was started at 1 g daily and increased to 1.5 g, if required. The therapeutic response was evaluated by a global assessment made by the patient and physician and regular PASI scoring. RESULTS: Good to excellent response was observed in 25 (73.5%) patients, less than 50% response in 7 (20.6%) patients, while 2 (5.9%) patients were lost to follow up. The mean PASI score was reduced by 76% at 10-12 weeks. Therapy was discontinued in 3 patients due to leukopenia that recovered on discontinuation of hydroxyurea. Patients were followed up to 1 year and relapse was observed in 5 patients. The duration of remission varied from 6 months to 1 year. CONCLUSION: Hydroxyurea is an effective and reasonably safe second line agent for psoriasis.

"Relatively spared zones" in leprosy: a clinicopathological study of 500 patients.

In this study, clinically all forms of lesions like macules, plaques, and nodules were found in all the "relatively spared zones," except groins. Histopathology confirmed that the disease process was established and the acid-fast bacilli were not present as a part of bacteremic settlement. Hence, it appears that practically no area on the surface of skin is immune to invasion by M. leprae. However, as the incidence of lesions and AFB in these regions is relatively less, especially over axilla and groin, these areas can be considered as relatively spared zones but not completely resistant to development of lesions of leprosy.

Atopy and alopecia areata in North Indians.

The study was undertaken with the aim of evaluating the effect of associated atopy on severity and age at onset of alopecia areata in north Indians. Presence of atopy was elicited by detailed history, examination and intracutaneous tests. Chi square test was carried out to evaluate statistical significance. One hundred patients (76 males and 24 females) with alopecia areata were evaluated. Historical evidence of atopy was present in 50 including patients alone (23), patients and first degree relatives (11) and first degree relatives alone (16). Intracutaneous tests were positive in 23 out of 50 patients tested randomly. There was a trend towards increasing frequency of severe alopecia as evidence of atopy became stronger e.g. both patient and first degree relatives with atopy or positive intracutaneous test but the results did not attain statistical significance. Similarly the age at onset and duration of alopecia areata was not significantly related to the presence of atopy. It is concluded that in north Indians with alopecia areata, the presence of atopy is not significantly associated with severe alopecia or onset at younger age.