Therapeutic Inertia in the Management of Psoriasis: A Quantitative Survey Among Indian Dermatologists and Patients.

Purpose: The primary objective of the study was to understand the therapeutic inertia in treatment and management of plaque psoriasis among dermatologists, along with determining the preferred treatment choices for management of plaque psoriasis; it also included the resulting treatment satisfaction among patients. The secondary objective was to identify the gaps in terms of knowledge and attitude among dermatologists and the expectations of patients. Patients and Methods: A multicentre, cross-sectional quantitative survey was conducted among dermatologists and patients with moderate to severe plaque psoriasis across India. The interviews were conducted either face to face or via telephone between September and November 2020, using structured and validated questionnaires based on specific themes. The data obtained were statistically analysed, wherever applicable. Results: Overall, 207 adult patients with moderate-to-severe plaque psoriasis and 303 dermatologists were interviewed. Post experiencing symptoms, 44% of the patients visited general physicians for treatment and there was an average 7.8-month delay by the patients to consult a dermatologist. Approximately one-fourth of patients used home remedies before seeking medical help. One-third of dermatologists used the Psoriasis Area and Severity Index (PASI) for assessing the disease severity. Majority of dermatologists preferred combination therapy for their patients. The lack of quick resolution and side effects were the major reasons for changing the treatment. Overall, only 35% of the patients complied to current treatment. Satisfaction with existing forms of therapies was highest for mild plaque psoriasis (62%) as confirmed by dermatologists, while 52% of the overall patients were satisfied with their therapy. Majority of the patients (64%) affirmed living with plaque psoriasis impacted their lives. Conclusion: This first-of-its-kind survey in India highlighted the gaps in terms of the disease journey between dermatologists and patients. The survey emphasises the need for shared decision-making and may benefit dermatologists in suggestive modifications of the treatment algorithm and disease management in clinical settings.

Alarming India-wide phenomenon of antifungal resistance in dermatophytes: A multicentre study.

BACKGROUND: An alarming increase in recalcitrant dermatophytosis has been witnessed in India over the past decade. Drug resistance may play a major role in this scenario. OBJECTIVES: The aim of the present study was to determine the prevalence of in vitro resistance to terbinafine, itraconazole and voriconazole in dermatophytes, and to identify underlying mutations in the fungal squalene epoxidase (SQLE) gene. PATIENTS/METHODS: We analysed skin samples from 402 patients originating from eight locations in India. Fungi were identified by microbiological and molecular methods, tested for antifungal susceptibility (terbinafine, itraconazole, voriconazole), and investigated for missense mutations in SQLE. RESULTS: Trichophyton (T.) mentagrophytes internal transcribed spacer (ITS) Type VIII was found in 314 (78%) samples. Eighteen (5%) samples harboured species identified up to the T interdigitale/mentagrophytes complex, and T rubrum was detected in 19 (5%) samples. 71% of isolates were resistant to terbinafine. The amino acid substitution Phe397Leu in the squalene epoxidase of resistant T mentagrophytes was highly prevalent (91%). Two novel substitutions in resistant Trichophyton strains, Ser395Pro and Ser443Pro, were discovered. The substitution Ala448Thr was found in terbinafine-sensitive and terbinafine-resistant isolates but was associated with increased MICs of itraconazole and voriconazole. CONCLUSIONS: The high frequencies of terbinafine resistance in dermatophytes are worrisome and demand monitoring and further research. Squalene epoxidase substitutions between Leu393 and Ser443 could serve as markers of resistance in the future.

Diagnosis and Management of Chronic Pruritus: An Expert Consensus Review.

The aim of this study is to formulate the best clinical practice in the diagnosis and management of chronic pruritus (CP). We searched PubMed, EMBASE, Scopus, Web of Science, and the WHO's regional databases, for studies on "Diagnosis and management of chronic pruritus" from January 1, 2014, to July 31, 2015. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data. We screened 87 of 95 studies that contained qualitative data. Avoid: Dry climate, heat, alcohol compress, ice packs, frequent bathing and washing, intake of very hot and spicy food, intake of alcohol, contact with irritant substances, excitement, strain and stress, and allergens. Using: Mild nonalkaline soaps, moisturizers, bathing oils, lukewarm water while bathing, soft cotton clothing and night creams/lotions, relaxation therapy, autogenic training, psychosocial education, educating patients to cope with itching and scratching, and educational programs. Especially use of moisturizers is considered important. In addition, symptomatic treatment options include systemic H1 antihistamines and topical corticosteroids. Symptomatic therapy directed toward the cause (hepatic, renal, atopic, polycythemia, etc.). If refractory or cause is unknown, consider capsaicin, calcineurin inhibitors for localized pruritus and naltrexone, pregabalin, ultraviolet therapy, Cyclosporine for generalized itching. CP is quite frequent finding associated with skin and systemic diseases in the overall population. It is known to significantly affect quality life score of an individual and also adds burden on the health-care cost. A specific recommendation for treatment of CP is difficult as a result of varied and diverse possibility of underlying diseases associated with CP.

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.

Short-term methotrexate therapy in psoriasis: a study of 197 patients.

Methotrexate (MTX) is one of the most effective antipsoriatic drugs available. Although it is undeniably hepatotoxic, it can be used safely in most patients with severe psoriasis if established guidelines are followed. Current opinion on the monitoring of hepatic damage is divided, however, and the need for repeated liver biopsies during MTX therapy is being re-examined. We have used MTX in a short-term protocol in our patients with psoriasis for the past 20 years, and have recently attempted to minimize or eliminate the need for liver biopsies using this regimen. Data on 244 psoriatics who were given MTX from 1981 to 2000 have been reviewed. Our protocol entailed the use of weekly oral MTX at the full therapeutic dose during episodes of peak disease activity, with tapering off of MTX when the disease subsided in response to treatment combined with natural/seasonal remission. Intensive topical and heliotherapy were encouraged throughout to facilitate the earliest possible drug withdrawal and the longest possible drug-free interval before the next relapse. Strict inclusion criteria were applied before starting MTX. A total of 243 cycles of MTX therapy have been given to 197 evaluable patients. More than 75% improvement occurred in 88% of patients in 8.5 +/- 5.1 weeks. The mean cumulative dose was 709.3 +/- 369.2 mg and the mean duration of follow-up was 16.5 +/- 9.1 months. Fifteen (6.1%) patients had serious adverse effects requiring the cessation of therapy. Only three patients had deranged liver function tests. Thirty-four pre-MTX and 13 post-MTX liver biopsies were taken, which revealed grade I or II changes that were nonprogressive. Our experience with short-term MTX therapy has enabled us to safely administer MTX to our patients with minimal recourse to liver biopsy. In developing countries, where advanced noninvasive methods for the assessment of liver damage are unaffordable or unavailable, this interrupted, short-term regimen may present an acceptable and safe method of using MTX in carefully selected patients with severe psoriasis.