Onychomycosis (OM) is a difficult-to-treat condition, especially considering the limited armamentarium of antifungal drugs, need for prolonged treatment, and poor compliance. This problem is further confounded while treating OM in special populations such as children, elderly, immunosuppressed patients, pregnant or lactating women, and patients with chronic liver or kidney disease. In the absence of standardized treatment guidelines, the antifungal therapy is either withheld or compromised, as it is largely governed by personal preferences or based on anecdotal reports. Hence, an expert group of the Nail Society of India worked towards drafting guidelines based on established literature and inputs from experts, with practical recommendations for the treatment of onychomycosis in special population groups. An extensive analysis of available English language literature on onychomycosis in special populations, published during a 10-year period (2014-2023 until date) was done. The available studies and reports were evaluated, cross-references read, and evidence compiled, graded, and discussed by the expert group to derive consensus recommendations for practice. The evidence and recommendations based on it are presented in a narrative format to guide treatment choices when dealing with population groups with special considerations.
Background: Community-acquired (CA) pyodermas are one of the most common infections encountered in the dermatology outpatient clinics. A significant number of these conditions are caused by Staphylococcus aureus. CA-methicillin-sensitive Staphylococcus aureus (MSSA) and CA-methicillin-resistant Staphylococcus aureus (MRSA) have specific virulence genes which are associated with these diseases, particularly the Panton-Valentine leukocidin (PVL) genes. The presence of the PVL gene as a virulence factor may be associated with recurrent and severe skin infections. Materials and Methods: A prospective study was conducted with 205 cases of CA pyodermas, of which five were discarded due to mixed isolates. Clinical details were taken and wound exudate was sent for bacteriological examination. Further, the molecular study was performed on all MRSA (7) isolates and 13 randomly selected MSSA isolates using polymerase chain reaction for mecA and PVL genes. Results: Staphylococcus aureus was the most common organism (90%) isolated from primary or secondary CA pyodermas. The prevalence of CA-MRSA among all pyodermas was 3.5% in our community. The PVL gene was not detected in all tested CA-MRSA and CA-MSSA isolates. Conclusion: While pyodermas are common, the prevalence of MRSA is low in the CA pyodermas in our region. PVL does not appear to be a virulence factor among the isolated MRSA. Larger, multicentric, and periodic studies are, however, required to further justify these claims.
Itraconazole (ITZ) has been the mainstay of oral antifungal treatment for the current epidemic of recalcitrant dermatophytosis (RD) in India. Recently, a newer formulation of ITZ, super bioavailable itraconazole (SUBA-ITZ), is made available in the market by many pharmaceutical companies. It is important for dermatologists to understand the pharmacokinetic properties of SUBA-ITZ vis-a-vis conventional pellet formulation to use it effectively and safely. Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) has established a special interest group for recalcitrant dermatophytosis (SIG-RD) to strengthen research, continuing medical education, and industry collaboration on the subject. This position statement on SUBA-ITZ by SIG-RD is an attempt to address current pieces of evidence and the position of this new formulation in the management of RD.
Chromoblastomycosis is a subcutaneous mycosis caused by a variety of dematiaceous fungi. Fonsecaea (F.) pedrosoi is the most common causative agent. Majority of cases have been reported from tropical and subtropical regions with rural and agricultural background. It is a chronic disease with low incidence of complications but is very refractory to therapies. This is a case series of 22 cases of chromoblastomycosis from two health-care facilities in India. Information regarding the history, clinical presentations, diagnostic methods, therapy, and outcome of treatment were retrieved. Preponderance was seen among the males and in the age group of 41-60 years. Manual and agricultural laborers were commonly affected. Lower extremities were the most common sites affected. Morphological patterns like verrucous plaque, psoriasiform plaque, and verrucous nodules were seen. Direct microscopy with potassium hydroxide (KOH) mount was positive in all the cases. Histopathology in all cases displayed suppurative granulomatous inflammation with pigmented fungal cells. Fungal culture was positive in 10 cases with F. pedrosoi being the commonest agent. Antifungal treatment alone was instituted in 10 cases, cryotherapy along with antifungal therapy was given in 9 cases, and surgical excision was done in 3 cases. Complete clinical cure was achieved in seven cases. Chromoblastomycosis is characterized by chronicity, diverse clinical presentations, and therapeutic recalcitrance. Direct KOH mount of the black dots forms an important bedside tool in the diagnosis. Long-term antifungal therapy along with adjuvant cryotherapy may be the best option for the management.
Introduction: Itraconazole follows non-linear pharmacokinetics and hence is recommended once daily, but in real-world practice, is commonly prescribed as twice daily. Hence, this study aimed to evaluate the efficacy and safety of super-bioavailable-itraconazole-130 mg (SB-130) and conventional-itraconazole-200 mg (CITZ-200) once daily compared with conventional-itraconazole-100 mg (CITZ-100) twice daily in glabrous tinea. Methods: A total of 261 eligible patients were enrolled in this prospective, randomized, clinical study from December-2021 to August-2022 at seven centers in India. Efficacy and safety assessments were done at week-3 and 6, with follow-up at week-10 for relapse. The primary objective was to assess the proportion of patients who achieved complete cure at week-6 following treatment in all itraconazole groups. The secondary outcomes were safety and clinical and mycological cure rates. Results: Of 261 patients, 240 were included in the analysis. At week-6, 140 patients were completely cured; thus, overall cure rate was 58.33%. Fifty-five patients (69%) in SB-130 while 47/77 (61%) and 38/83 (46%) patients were completely cured in CITZ-200 and CITZ-100 groups respectively (p<0.05; SB-130: CITZ-100, p=0.32; SB-130: CITZ-200, p=0.058; CITZ-200: CITZ-100). There was no statistical difference in the mycological cure rate and area clearance rate between any of the groups (p=0.14); however, a statistically significant difference was noted for OD dosing over BD dosing in achieving clinical cure rates (p<0.05). A total of 13/140 patients (9%) relapsed following complete cure, with no statistically significant difference between any of the groups (p=0.50). All treatments were safe and well-tolerated, with no discontinuation. Conclusion: In this clinical study, moderate efficacy with all doses of ITZ was reported but was better with OD dosing. Although there was no statistical difference between SB-130 and CITZ-200, SB-130 may be preferred over CITZ-200 owing to the advantage of SB over the conventional ITZ.
Itraconazole , Tinea , Humans , Itraconazole/therapeutic use , Antifungal Agents , Prospective Studies , Neoplasm Recurrence, Local/drug therapy , Tinea/drug therapy , Treatment Outcome
Background: Psoriasis, a chronic, immune-mediated skin disorder, has systemic manifestations as well as an ample negative impact on the quality of life (QOL) of the patient. An abnormal proliferation of keratinocyte and dermal infiltration by immune cells is a characteristic feature. It involves components of both innate and adaptive immunity, and the interaction of T cells with macrophages. Keratinocytes and dendritic cells are mediated by the secreted cytokines. This study was taken up to look into changes at the molecular level that occur during the expression of three cytokines namely tumour necrosis factor-alpha (TNFα), interleukin 17A (IL-17A) and interleukin 6 (IL-6) in Indian patients with psoriasis. Methods: A case-control study was conducted with samples from 15 psoriasis vulgaris patients and 10 healthy control subjects. Clinical parameters were recorded. Blood samples were analysed for peripheral blood messenger ribonucleic acid (mRNA) expression of TNFα, IL-17A and IL-6 using real-time polymerase chain reaction (RT-PCR). Results: The mRNA expression of TNFα, IL-17A and IL-6 in psoriasis patients were increased as compared to that in normal subjects. Conclusions: The elevated levels of Interleukins indicates a systemic inflammatory process that is akin to the cutaneous inflammation. This study indicates that the targeted therapies against these cytokines are likely to be beneficial in Indian psoriasis patients.
BACKGROUND: There has been an alarming increase in the prevalence of chronic, recurrent and steroid modified dermatophytosis of the glabrous skin in the recent years in India. There is paucity of literature on the magnitude of this major public health problem. OBJECTIVE: To estimate the prevalence of dermatophytosis and clinico-epidemiological features of chronic and recurrent dermatophytosis (CRD) across India and to evaluate the associated risk factors. METHODS: This is a multicentric descriptive cross-sectional study conducted in 13 centres situated across India in two phases during dry and rainy seasons. All consecutive patients presenting with dermatophytosis were screened during the study period of 14 consecutive working days. Patients with CRD of the glabrous skin as per the case definition were included after exclusion of isolated hair and nail infections. Demography, clinical findings and results of potassium hydroxide wet mount were recorded. RESULTS AND CONCLUSION: A total of 41,421 patients were screened, out of which 7174 (17.31%) patients had glabrous dermatophytosis. CRD was observed in 1999 (27.86%) patients with 78.08% and 21.95% of chronic and recurrent dermatophytosis, respectively. Family history was present in 50.03% of patients. History of sharing of fomites was present in 50.37% of them. Synthetic tight clothes were worn by 43.47%, while 50.9% gave history of misuse of topical corticosteroid creams. Multiple site involvement was common (69.58%) with tinea cruris (79.99%) and tinea corporis (75.69%) being the most common clinical types. CRD is associated with sharing of fomites, topical corticosteroid misuse and involvement of multiple sites.
Tinea , Cross-Sectional Studies , Glucocorticoids , Humans , India/epidemiology , Recurrence , Tinea/epidemiology
Cutaneous, mucosal, and nail examination is the key to unveiling a plethora of systemic diseases. Mucocutaneous lesions directly related to human immunodeficiency virus (HIV) infection usually present as initial manifestations of immune deficiency, of which few lesions act as predictors of an immunocompromised state. Here, we report two cases who presented with onycho-mucocutaneous symptoms which raised the suspicion of and invariably led to the diagnosis of an underlying immunosuppression secondary to HIV infection.
INTRODUCTION: Periorbital melanosis (POM) is an esthetic facial concern on increasing trend and has a severe emotional impact on patients. We aimed to study the clinical and dermoscopic patterns of periorbital melanosis to aid in the classification and strategize therapy. METHODS: A cross-sectional, observational study was conducted on one hundred patients with POM in a tertiary care center in India from January 2020-March 2020. Dermoscopic assessment of POM was done using video dermatoscope- FotoFinder Medicam 1000s (magnification up to 140x). RESULTS: The mean age of participants was 32.8 ± 9 years. It was more prevalent among females (78%). The constitutional type (43%) of POM was the most common followed by shadow-effect type (32%). The various dermoscopic pigmentary patterns seen were scattered pigmented dots (56%), exaggerated pigment network (31%), globules (30%), and blotches (27%). Dilated veins and telangiectasia were seen in 50% and 32% of subjects, respectively. Exaggerated skin markings were seen in 43% of participants. Scattered pigmented dots were most commonly seen in constitutional, vascular, and shadow types but were significantly associated with vascular type. Exaggerated pigment network was the most frequent pigmentary pattern in post-inflammatory type of POM. Globules were significantly associated with constitutional as well as shadow type of POM and blotches with shadow type of POM. CONCLUSIONS: Periorbital melanosis presents as multifactorial entity with constitutional type being the most common. The dermoscopic patterns of POM may provide a clue to the underlying etiology, thereby helping to plan appropriate treatment.
Melanosis , Skin Neoplasms , Adult , Cross-Sectional Studies , Dermoscopy , Female , Humans , Melanosis/diagnostic imaging , Tertiary Care Centers , Young Adult
CONTEXT: There is an alarming rise in the incidence of chronic and recurrent dermatophytosis (CRD) in India. Many factors including tinea unguium may be responsible for it. AIMS: To evaluate various epidemiological and clinical factors including the presence of tinea unguium as a risk factor for CRD. SETTINGS AND DESIGN: This was a case-control study in which patients attending the dermatology outpatient department of a tertiary care hospital in February-March 2019 were recruited. A total of 80 consecutive clinically diagnosed patients with CRD as per the case definition (cases) were selected. Another 80 consecutive patients with dermatophytosis other than CRD (controls) were also selected. Patients were clinically evaluated with special attention for the presence of tinea unguium. RESULTS: Among the total of 80 cases, 44 (55%) and 36 (45%) were diagnosed to have chronic dermatophytosis and recurrent dermatophytosis respectively. CRD was relatively uncommon in patients younger than 20 years. Sharing of linen, family history, and topical corticosteroid abuse were also frequent among patients with CRD. Tinea unguium was present in six cases (7.5%) and two controls (2.5%) which was not statistically significant (P = 0.27). CONCLUSIONS: The current epidemic of CRD may be primarily due to a pathogen with certain specific epidemiological and clinical determinants. It may be primarily a skin pathogen with less or no affinity toward the hair and nail.
BACKGROUND AND AIMS: Dermatophytosis has always been a common superficial mycosis in India. However, the past 6-7 years have seen an unprecedented increase in the number of patients affected by recurrent, chronic, recalcitrant and steroid modified dermatophytosis involving the glabrous skin (tinea corporis, tinea cruris and tinea faciei). Importantly, there has been a notable decrease in clinical responsiveness to commonly used antifungals given in conventional doses and durations resulting in difficult-to-treat infections. Considering that scientific data on the management of the current epidemic of dermatophytosis in India are inadequate, the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task force Against Recalcitrant Tinea (ITART) has formulated a consensus statement on the management of dermatophytosis in India. METHODS: Seventeen dermatologists with a focussed interest in dermatophytosis participated in a Delphi consensus method, conducted in three rounds. They responded as either "agree" or "disagree" to 132 statements prepared by the lead experts and gave their comments. Consensus was defined as an agreement of 80% or higher concurrence. Statements on which there was no consensus were modified based on the comments and were then recirculated. The results were finally analysed in a face-to-face meeting and the responses were further evaluated. A draft of the consensus was circulated among the participants and modified based on their inputs. RESULTS: Consensus was achieved on 90 of the 132 statements. Direct microscopy using potassium hydroxide mount was recommended in case of diagnostic difficulty on clinical examination. Counselling of patients about strict adherence to general measures and compliance to treatment was strongly recommended as the key to successful management of dermatophytosis. A combination of systemic and topical antifungal drugs was recommended for the treatment of glabrous tinea in the current scenario. Topical corticosteroid use, whether used alone or in combination with other components, was strongly discouraged by all the experts. It was suggested that topical antifungals may be continued for 2 weeks beyond clinical resolution. Itraconazole and terbinafine were recommended to be used as the first line options in systemic therapy, whereas griseofulvin and fluconazole are alternatives. Terbinafine was agreed to be used as a first line systemic agent in treatment naïve and terbinafine naïve patients with glabrous tinea. Regular follow-up of patients to ensure compliance and monitoring of clinical response was recommended by the experts, both during treatment and for at least 4 weeks after apparent clinical cure. Longer duration of treatment was recommended for patients with chronic, recurrent and steroid modified dermatophytosis. CONCLUSION: Consensus in the management of dermatophytosis is necessary in the face of conventional regimens proving ineffective and dearth of clinical trials re-evaluating the role of available antifungals in the wake of evolving epidemiology of the infection in the country. It needs to be backed by more research to provide the required level of evidence. It is hoped that this consensus statement improves the quality of care for patients with dermatophytosis, which has emerged as a huge public health problem, imposing considerable financial burden on the country.
CONTEXT: Connective tissue disorders (CTD) occur in 3-5% of the population. The advent of antibodies to extractable nuclear antigens (ENA) has become a reliable predictor to establish the diagnosis of CTD, subclassify patients into prognostic groups, and monitor disease activity. AIMS: The aim of this study was to (a) study the frequency of cutaneous manifestations, systemic manifestations, and anti-ENA antibodies in CTD; (b) determine the association between systemic manifestations and ENAs; and (c) determine the association between cutaneous and systemic manifestations of CTD. SUBJECTS AND MATERIALS: An observational cross- sectional study was conducted on 50 patients diagnosed to have CTD. The clinical profile and antibodies to ENA (ANA Profile) reports were retrieved and studied. RESULTS: The major dermatological manifestations were skin tightness (36%), salt and pepper pigmentation (30%), Raynaud's phenomenon (28%), and malar rash (28%). The common antibodies seen were anti SS-A (36%), anti-UI-ribonucleoprotein (U1-RNP) (34%), anti-dsDNA (32%), and anti-Sm (24%). Patients with anti-Sm and anti-dsDNA antibodies had increased frequency of renal manifestations. A strong association with significant P values was seen between neurological manifestations and anti-Sm antibody, and cardiovascular manifestations and anti-RNP antibody. An association between gastrointestinal manifestations and malar rash as well as neurological manifestations and photosensitivity was also seen. CONCLUSIONS: ENA panel predicts systemic involvement, thus helping in the multidisciplinary management. Cutaneous manifestations of CTD can be an early predictor in giving a clue to impending systemic manifestations.
Venous leg ulcers are the most common form of non-healing leg ulcers. They are subjected to treatments such as topical medications, dressings, and compression therapies. This can lead to exposure to a number of allergens with subsequent sensitisation and contact dermatitis of the regional skin. This may contribute to the poor ulcer healing. To detect the various contact sensitisers in patients with venous leg ulcers through patch testing, patients from 6 centres across India with venous leg ulcers of longer than 6 weeks duration were enrolled for the study. They were patch tested using a special parch test kit with 27 antigens. A total of 172 patients were included in the study; 82 (48.2%) tested positive for at least 1 antigen. Among them, polyvalent sensitisation was noted in 71% of patients. Wood tar mix (10.4%) and the framycetin (8.7%) were the most common allergens. There is a high frequency of allergic sensitisation to various ingredients of topical therapies used in the venous ulcer management, which may interfere with wound healing. Avoiding them can help obtain a better therapeutic outcome.
Allergens/analysis , Bandages/adverse effects , Dermatitis, Allergic Contact/diagnosis , Dermatitis, Allergic Contact/therapy , Leg Ulcer/drug therapy , Varicose Ulcer/drug therapy , Wound Healing/physiology , Adolescent , Adult , Aged , Aged, 80 and over , Dermatitis, Allergic Contact/etiology , Female , Humans , India , Male , Middle Aged , Patch Tests , Young Adult
