Comparative evaluation of the efficacy of itraconazole with terbinafine cream versus itraconazole with sertaconazole cream in dermatophytosis: A within person pilot study.

Background: Current trend of rising drug-resistant dermatophyte infection is alarming and fretted by dermatologists. Dilemma prevails regarding use of the same or different class of antifungal agents topically and systemically. The aim was to study the efficacy of oral itraconazole 200 mg with 1% terbinafine cream versus oral itraconazole 200 mg with 2% sertaconazole cream in dermatophytosis. Methods: This within-person open-label pilot study enrolled 50 patients with dermatophytosis. Two lesions of comparable size within each patient were randomly allotted to group A and B and treated with 2% sertaconazole and 1% terbinafine cream, respectively. Both groups received itraconazole 200 mg once daily for 4 weeks. The remaining lesions received 1% terbinafine cream. Response and adverse effects were assessed at 2 and 4 weeks. Reduction in erythema, scaling, pruritus and clinical, and mycological cure constituted efficacy outcomes. Results: The mean duration of lesions was 2.82 ± 1.35 months. Complete clinical cure was observed in 50% and 48%, whereas mycological cure was attained in 56% and 52% patients in groups A and B, respectively, after 4 weeks, which was statistically insignificant. Reduction in erythema, scaling, and pruritus after 4 weeks when compared between the two groups, was also statistically insignificant. Conclusion: Same class of oral and topical antifungal agents has comparable efficacy with different classes of oral and topical antifungal agents in dermatophyte infection.

Falkner's needling technique for the treatment of warts: Minimum investment, maximum benefit.

Background: Verruca vulgaris is a viral infection with high recurrence rates and is very difficult to treat. It occurs due to the ability of the virus to evade immune recognition. This immune evasion by the human papillomavirus (HPV) can be circumvented by injecting HPV antigens subcutaneously and inducing inflammation and a systemic immune response. Falkner technique is an approved technique for the treatment of warts. In this observational study, we analyzed the recovery rate among patients undergoing this technique as part of their routine treatment. The aim of this study is to study the clinical outcome of Falkner's needling technique that is being used for the treatment of verruca vulgaris. Methods: Under local anaesthesia, only a single wart was vertically punctured using a 26-gauge needle up till the subcutis multiple times till bleeding was observed. No treatment was done for other warts. Patients were advised not to take any anti-inflammatory medications for pain and were observed for responses after 1 week as well as 1 and 3 months. Results: Of 41 patients included in this study, the total resolution of both the punctured and distant warts occurred in 28 patients (68.29%) and partial response in 7 patients (17.1%) by the end of 3 months. Interestingly, individual warts that were subjected to needling showed complete resolution in 35 patients (85.4%). Conclusion: Falkner's needling method provides a high rate of complete resolution of multiple warts at both the needled and distant sites after a single treatment session of only a single lesion. This modality has a high cure rate, is easy to perform, requires minimal infrastructure support, is cost-effective, and can be undertaken at most peripheral settings with minimal training.

Drug reaction with eosinophilia and systemic symptoms: A single center descriptive observational study.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse cutaneous drug reaction with mortality up to 10%. It is a rare condition with risk varying between 1 in 1000 and 1 in 10 000 drug exposures. The aim of the study was to describe clinical features, management and drugs responsible for causing DRESS. The study was retrospective, observational study. The data of patients admitted to hospital with diagnosis of DRESS during study period (March 2018 to February 2020), were retrieved and analyzed. The descriptive data of patients were summarized. The continuous variables were summarized as mean ± SD and/or median, depending on the skewness of the data. The categorical variables were expressed as absolute numbers, frequency, and proportions (%). The data was tabulated and analyzed in Microsoft Excel 2019 version. A total of 20 patients who met inclusion criteria (probable or definite DRESS as per RegiSCAR criteria) were included in the study. The mean age of the patients was 41.2 ± 15.7 years. The average latency period was 26.45 ± 5.65 days (range: 7-60). The commonest culprit drugs were dapsone and phenytoin, each in five (25%) patients. Commonest morphology of rash was morbilliform in 13 (65%) patients. One patient with targetoid rash had multi-organ involvement. Facial edema, periorbital edema, and conjunctival injection were seen in 17 (85%), seven (35%), and six (30%) cases, respectively. Eosinophilia was present in 18 (90%) patients with mean (±SD) value of 1976 ± 840 cells/µl. Liver was the commonest internal organ involved in 14 (70%) patients and kidney in three (15%) patients. The initial dose of prednisolone for treatment varied from 0.75 to 2 mg/kg/day. The mean duration of steroid treatment was 64 ± 21 days. Two patients were treated with intravenous methylprednisolone and one with intravenous immunoglobulin. Two patients (10%) had recurrence of adverse drug reaction >6 months after completion of initial treatment and two (10%) developed autoimmune thyroiditis during follow-up. Small sample size and retrospective nature of the study were main limitations. Selection bias is a possibility as study was carried out in tertiary care center. Tests for incriminating culprit drugs such as patch test, intradermal test, and lymphocyte transformation test were not performed. DRESS is a rare disease that can be diagnosed early with high index of suspicion and treated successfully with steroids. The internal organ involvement is common in DRESS and requires a thorough evaluation.

Copper-impregnated socks: A novel therapeutic option for combating occupational dermatophytosis.

BACKGROUND: Operational and training requirements of soldiers necessitate prolonged use of occlusive footwear which makes them susceptible to Tinea pedis and affects their performance. This study assesses copper oxide-impregnated socks as a treatment modality in soldiers with Tinea pedis. METHODS: Three hundred serving soldiers with Tinea pedis were randomly divided in two groups of 150 cases each. One group was supplied with 02 pairs of polyester copper oxide-impregnated socks and the second group was treated with oral terbinafine 250mg /day for two weeks and topical terbinafine twice a day for three weeks. Five end points viz. scaling, erythema, fissuring, vesicular eruptions and itching were monitored using the visual analogue score (VAS) weekly for 03 weeks. RESULTS: Copper oxide socks helped in reducing all the end points as assessed by VAS. The group treated with terbinafine showed better response; however test socks were as efficacious as oral and topical terbinafine in controlling fissuring and vesiculation. Safety profile of the copper impregnated socks was comparable with the conventional treatment. CONCLUSION: Copper-impregnated socks are effective and safe in treating Tinea pedis. They may also have prophylactic role in tinea pedis in susceptible serving soldiers deployed at remote locations in different terrain and weather conditions.

Trichoscopy of Pressure-Induced Alopecia and Alopecia Areata: A Comparative Study.

Background: Pressure-induced alopecia is an uncommon type of alopecia. It can occur in both scarring as well as non-scarring form and occurs due to ischemia resulting from prolonged head immobilisation during surgery or hospitalisation. The patchy hair loss generally involves convexities of scalp specially vertex and occiput. The hair loss is usually noticed 3 -28 days after the inciting event and regrowth of hair occurs between 1 - 4 months. Objective: To describe trichoscopic features of pressure alopecia and compare it with the closest differential, alopecia areata. Methodology: It is a retrospective observational study. Trichoscopic features of six cases of pressure alopecia seen during the study period were compared with alopecia areata and analyzed using appropriate statistical methods. Results: The study had 30 cases, six cases of pressure alopecia and 24 cases of alopecia areata. The mean age of patients with pressure alopecia and alopecia areata was 45.16 and 29.08 years respectively. Comedone- like black dots, black dots and area of scarring were statistically significant for pressure alopecia while exclamation mark hairs were significant for alopecia areata. Conclusion: Trichoscopy is a non-invasive test for diagnosis of alopecia and "Comedone-like black dots" are unique trichoscopic feature of pressure alopecia.

Comparison of Interferon Gamma Release Assay and Tuberculin Skin Test for Diagnosis of Latent Tuberculosis in Psoriasis Patients Planned for Systemic Therapy.

Background: Latent tuberculosis infection (LTBI) is a common yet difficult problem to diagnose in tuberculosis endemic countries. Both tuberculin skin test (TST) and interferon-gamma release assay (IGRA) are used for the diagnosis of LTBI. Aims: The aim of the study is to compare TST and IGRA in patients planned for systemic treatment of psoriasis. Methods: It was a diagnostic study conducted in a tertiary care centre during the study period from January 20 to December 20. Patients more than 18 years of age with chronic plaque psoriasis planned for systemic therapy were included. Psoriasis area severity index (PASI), history of tuberculosis in past or family and BCG vaccination were recorded. Complete blood count, radiograph of the chest, tuberculin skin test and interferon-gamma release assay were performed in all patients. Statistical analysis was performed using statistical package for social sciences (SPSS version 20, Chicago). Results: A total of 75 patients, including 48 males and 27 females, were included in the study. The mean age and mean duration of disease were 46.08 (±12.16) and 4.59 (±3.8) years, respectively. Seventy-one (94.6%) patients had BCG scar, and two (2.6%) had a history of tuberculosis in a family member. The TST and IGRA were positive (>10 mm) in 23 (30.6%) and 16 (21.3%) patients, respectively. Either TST or IGRA was positive in 28 (37.3%) patients. Out of these 28 patients, concordance was seen in 11 (39.2%) and discordance in 17 (60.7%). Discordance was TST+/IGRA - in 12 (42.8%) and TST-/IGRA + in five (17.8%) patients. Abnormality in radiograph of the chest and computed tomography (CT) scan of the chest were seen in five (6.6%) and nine (12%) patients, respectively. The patients with either TST or IGRA + were more likely to have abnormal chest radiographs than those who were TST-/IGRA- (OR: 11.3, 95% CI: 1.24-102.3, P = 0.03). The TST and IGRA showed fair agreement ( = 0.364, P = 0.003). ROC curve was plotted for the absolute value of TST in mm considering IGRA as the gold standard. The area under the curve was 0.805 (95%CI: 0.655-0.954). For the TST positivity cut-off of 10 and 15 mm, specificity was 77.3% and 95.5%, respectively; the sensitivity was 68.8% irrespective of the cut-off value. Limitation: Small sample size and lack of follow-up are the biggest limitations of the study. The lack of a gold standard in the diagnosis of LTBI is an inherent yet unavoidable flaw in the study. Conclusion: Reactivation of LTBI is a concern in a patient planned for immunosuppressive therapy. We suggest the use of both TST and IGRA rather than two-step testing (TST followed by IGRA) or IGRA alone for the diagnosis of LTBI, especially in patients with a high risk of reactivation. The positivity on either test should prompt further evaluation and treatment decisions should be taken considering the risk-benefit ratio of treatment rather than test results alone.

Dermatology practice in the times of the COVID-19 pandemic.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is implicated in the ongoing pandemic across the globe since December 2019. It was first notified by China from Wuhan on 31 December 2020 and transmission to healthcare workers was first reported on 20 January 2020. Human-to-human transmission is mainly by droplet infection. At present no effective vaccine is available. Our speciality needs to collectively address the urgent issue of risk of transmission in dermatology practice. A case series of Coronavirus Disease 2019 (COVID-19) from Wuhan described that 41.3% of their patients may have acquired the infection from the hospital. Of all the infected health care workers, 77.5% worked in general wards and departments. These data highlight the significant risk of nosocomial transmission of COVID-19 and also the higher risk in general wards and departments compared to the emergency room or intensive care unit. Dermatology patients are generally seen in clinics and in outpatient departments in hospitals. Patients wait together in the waiting area, intermingle and then are seen by the physician in their chamber. This can cause transmission of the pathogen among patients and from patient to physician. Social distancing, hand hygiene and the use of personal protective equipment are important for preventing the spread of infection and dermatology practices also have to incorporate these aspects. Telemedicine is becoming an important tool for the management of dermatology patients in these times. At-risk patients in dermatology also need to be given priority care. Protocols for the use of immunosuppressants and biologics in dermatology during the pandemic are being developed.

Follicular Graft Vs Host Reaction: A Rare Presentation.

Graft versus host disease (GVHD) is a unique entity wherein the donated marrow cells (graft) view the hosts as foreign and attack various body organs. Skin is the most frequently affected organ followed by mucosa, eyes, gastrointestinal, respiratory, musculoskeletal system, and other organs. The incidence of GVHD varies from 25 to 80%. Cutaneous involvement can present as exanthem, epidermolysis, lichenoid eruptions, erythroderma, ichthyosis, pityriasis rubra pilaris like lesions, psoriasiform lesions or just pruritus. Asymptomatic truncal follicular eruptions as the major presentation is rare. We report a case of aplastic anemia that developed extensive truncal folliculocentric papules 10 months following an allogeneic hematopoietic stem cell transplantation. Histopathological examination of the follicular lesions revealed perifollicular inflammatory infiltrate comprising of lymphocytes, plasma cells and histiocytes at the dermo-epidermal junction. Basal cell vacuolization, pigment incontinence in the upper dermis and few apoptotic keratinocytes in the follicular epidermis were also seen. The patient responded satisfactorily to tapering doses of steroids.

A Rare Case of Possible Vacuolar Degeneration of Leprosy in Brain with Segmental Necrotizing Granulomatous Neuritis and Horner's Syndrome.

Leprosy has a predilection for peripheral nerves, but rarely does it involve the central nervous system (CNS). There is a single study of CNS involvement in leprosy showing vacuolar changes of motor neurons in medulla oblongata and spinal cord in autopsy findings. Besides this, there has been only one case report providing direct histopathological and molecular evidence of CNS involvement by leprosy in a living patient. Segmental necrotizing granulomatous neuritis (SNGN) is a rare condition affecting the peripheral nerves in leprosy usually seen as a complication of tuberculoid (TT) and borderline tuberculoid (BT) leprosy. We report the case of a 23-year-old male patient, a case of Hansen's disease (BT) who developed CNS involvement in the form of partial Horner's syndrome (right) and SNGN while on treatment. Magnetic resonance imaging of the brain revealed T2 hyperintense lesion on the dorsal aspect of left pontomedullary junction, suggestive of vacuolar degeneration of leprosy. Histopathology of greater auricular nerve (right) revealed SNGN.

Acute scrotum: Hansen's disease versus filariasis.

Hansen's disease is caused by Mycobacterium leprae. The disease is known to involve the visceral organs including the testis apart from the skin and nerves in the lepromatous pole of leprosy due to widespread hematogenous dissemination of lepra bacilli. Furthermore, there can be testicular pain during the type 2 reaction in Hansen's disease. Filariasis is a disease caused by the parasitic nematode, Wuchereria bancrofti. This infection most commonly results in lymphedema and secondary vaginal hydrocele with an associated epididymo-orchitis. Acute epididymo-orchitis is either seen in the acute phase or as a part of secondary bacterial infections. The particular interest of this paper is to report the case of Hansen's disease who presented with testicular pain and posed a diagnostic dilemma when his pain did not respond to the standard mode of treatment and an alternate rare diagnosis was sought. This case report also emphasizes the need of reconsideration of diagnosis when the patient is not responding to standard therapy.