Oral Lichen Planus: An Updated Review of Etiopathogenesis, Clinical Presentation, and Management.

Lichen planus (LP) is a chronic idiopathic immune-mediated inflammatory condition. LP is a heterogeneous disease with varied clinical presentations having different natural history, prognosis, sequelae, and outcomes. It can affect skin, hair, nails, and mucosae. Mucosal LP (including oral LP) tends to be persistent and resistant to treatment, compared to cutaneous LP. Oral LP (OLP) is broadly divided into two main categories: hyperkeratotic (usually asymptomatic) and erosive (commonly symptomatic). It can present with symptoms including odynophagia, dysphagia, dysgeusia, and sensitivity to hot spicy foods. Apart from the superficial epidermal changes, which vary with the type of clinical presentation, histopathologically oral LP shows a unifying similar and consistent feature of a lichenoid interface dermatitis. Recently, researchers have highlighted the critical role played by IL-17 in the pathogenesis of OLP. World Health Organization has categorized oral LP as one of the oral potentially malignant disorders (OPMD), albeit with a low risk of malignant transformation. Also, in the last couple of years there have been various reports on the usage of newer drugs like anti-IL17, anti-IL12/23, anti-IL 23, PDE4 inhibitors, and JAK inhibitors in the management of refractory OLP. The principal aim of treatment still remains to resolve the symptoms, prolong the symptoms free period, and reduce the risk of potential malignant transformation. We have described many new revelations made in recent times regarding the etiopathogenesis, associated conditions as well as management of OLP. Thus, the objective of this review is to present a comprehensive up-to-date knowledge including the recent advances made regarding OLP.

Topical Therapy in Psoriasis.

Psoriasis is a chronic condition that progresses in remitting and relapsing phases. Most of these patients have mild-to-moderate illness, which can be managed with topical medications or could be thought of as continuing therapy after remission. Potential therapeutic efficacy is offered, and systemic treatment's negative side effects are constrained. Topical therapies have recently advanced in tandem with recent advancements in our understanding of psoriasis. To improve the quality of life of patients, appropriate knowledge and application of these topical agents are crucial.

Disease Assessment in Psoriasis.

Researchers are making all out efforts worldwide, to find a serological marker to monitor the disease severity and/or measure efficacy of the drug. There are many potential molecular targets being investigated as a candidate marker. However, till date there has been no significant breakthrough. Thus, various scoring systems have been devised to evaluate the disease severity in psoriasis. In spite of constant revisions of the scores being currently used, from time to time. None of the scores yet satisfy all the validation criteria desired of an ideal scoring system. And this is partly also because of the fact that the psoriasis has such a huge range of clinical variants. Nevertheless, in the recent past, significant progress has been made in this direction.

Biologics and Biosimilars in Psoriasis.

Psoriasis is a chronic, debilitating, relapsing, inflammatory dermatosis, which affects approximately 2-3% of the population. The burgeoning research on pathogenesis of psoriasis has opened up new directions in management of this common condition. The introduction of biologics has given additional elements to the arsenal of psoriatic disease treatments. TNF-α inhibitors, IL-12/23 inhibitors, IL-17 inhibitors, CD-6 inhibitor proved highly efficient and have a good safety profile in numerous clinical trials. Biosimilar drugs are structurally almost similar to their reference biologic and are also made from living organism. Long-term follow-up and post-marketing surveillance are required to understand, long-term efficacy, adverse events of these powerful potent molecules.

Intravascular Papillary Endothelial Hyperplasia Involving the Hand: A Case Report of a Rare Entity.

Masson's tumor, also named intravascular papillary endothelial hyperplasia (IPEH), is a rare, benign vascular tumor. Evaluation by clinical features can be confused with other soft tissue tumors. Therefore, the diagnosis should be confirmed by histopathological examination. The patient reported here is 67 years old and came to us with a small painful lesion over the left thumb of about two months duration. Histopathological examination was consistent with Masson's tumor (IPEH) following excisional biopsy, with good functional outcomes. To the best of our knowledge, this is the first report of this entity from Kuwait. Dermatologists and surgeons should know about this rare entity and its unusual presentation, to be able to distinguish it from similar presenting serious conditions, especially angiosarcoma. Through this report, we purport to facilitate recognition of this condition apart from some other conditions it may mimic.

Coronavirus Disease of 2019 (COVID-19) Facts and Figures: What Every Dermatologist Should Know at this Hour of Need.

Coronavirus disease of 2019 (COVID-19) pandemic has affected India and the world as a whole, like nothing in the recent history and we, dermatologists, are also affected directly or indirectly. In this review, we have tried to address the COVID-19-related information we need to be aware of as a health-care professional. We have discussed the relevant details of the disease: the agent, the symptomatology, common preventive measures, investigations, and management outline. We have also discussed the implications of COVID-19 in dermatology practice and given a basic guideline for dermatology practice during the pandemic.

Follicular Becker's Nevus: A New Clinical Variant.

Becker's nevus, also known as pigmented hairy epidermal nevus, is characteristically described as a unilateral, hairy, light to dark brown macule with sharply outlined but irregular border. The etiopathogenesis of Becker's nevus is still not clearly understood. Perifollicular pigmentation has been described earlier by some authors. But, Becker's nevus presenting exclusively with follicular lesions has not been described. We are reporting a series of patients of Becker's nevus with follicular lesions. The diagnosis in all the patients was made after clinicopathological correlation. Follicular epithelium may hold a significant role in the etiopathogenesis of Becker's nevus.

Controversies in the Management of Cutaneous Adverse Drug Reactions.

Some cutaneous adverse drug reactions (CADRs) are severe life-threatening conditions due to multisystem involvements with a high morbidity and mortality rates ranging from 25 - 70% and require immediate medical care. But there are huge controversies regarding the management because large clinical trials are lacking. Most frequent discussion and division occur regarding the use of systemic corticosteroid as early intervention with corticosteroids controls inflammation. Corticosteroids are potent agents that target several intracellular processes to modify almost all components of inflammatory and immune responses but their impact on the long term disease course is not known. Controlled relapses of rash and hepatitis may occur as corticosteroids are tapered. A chronic HHV6 activation promoted by systemic steroids could explain these relapses. Second important issue is the use of antitubercular drugs (ATD) in case of CADR due to multidrug therapy of ATD. As both the tuberculosis and CADR are life threatening conditions and we can not spare treatment of tuberculosis for CADR, we should come to a conclusion which is not yet decided. In the same way the use of antileprotic MDT in CADR due to MDT raises a similar controversy. So, here we focus on those controversies and discuss the issues.

How useful is the Mantoux test in the diagnosis of doubtful cases of cutaneous tuberculosis?

BACKGROUND: Diagnostic tests are critical to management when the clinical picture is unclear. We analyzed the records of patients in whom the initial diagnosis of cutaneous tuberculosis was doubtful to evaluate the utility of the Mantoux test in this setting. MATERIALS AND METHODS: Of 375 patients with cutaneous tuberculosis seen in our department, the initial clinical diagnosis was doubtful in 90 patients. A Mantoux test was performed with 5 TU of purified protein derivative using standard techniques and read after two days. Patients also underwent skin biopsy and other laboratory tests and received treatment with antitubercular drugs. Patients who had case notes recording satisfactory improvement following antitubercular therapy were classified as having cutaneous tuberculosis; those with evidence of another diagnosis based on the laboratory tests and response to therapy were categorized as non-tuberculosis cases. Patients with inadequate evidence for a diagnosis of either cutaneous tuberculosis or another disorder were classified as unresolved diagnosis. RESULTS: Readings were available in 79 patients: 39 were categorized as tuberculosis; 16 as non-tuberculosis; while a final diagnosis could not be reached in 24 cases. Readings ranged from 0 to 40 mm in the cases and from 0 to 30 mm in non-cases. The area under the receiver-operating characteristic curve was 0.66 (95% CI 0.55-0.81). Using a cut-off of 10 mm, the sensitivity and specificity of the tests were 58.97 and 62.50%, respectively. CONCLUSION: The Mantoux test is of low accuracy in the diagnosis of doubtful cases of cutaneous tuberculosis.

Tattooing in the Gulf region: a review of tattoo practices and response to treatment with the Q-switched ruby laser.

BACKGROUND: Data regarding tattoo practices in the Gulf region and response to treatment are almost non-existent in the medical literature. OBJECTIVE: To study the profile of patients with permanent tattoos in the Arab world, and to evaluate their response to Q-switched ruby laser treatment. METHODS: A total of 468 consecutive patients with permanent tattoos consulting us for tattoo removal were recruited in the present study. Before starting the treatment each patient was given a set of questionnaires to answer. The patients were then treated with the Q-switched ruby laser, with a time interval of 8 weeks between each laser session, until complete clearance or up to a maximum of 10 sessions. RESULTS: A total of 292 patients out of 348 patients achieved excellent lightening to complete clearance of tattoo pigment after an average of six sittings (range 2-10 sittings). Female patients with fair complexions and amateur tattoos on the face responded best. Seventy-eight (22.4%) patients developed pigmentary changes. CONCLUSION: More females than males had tattoos, and at a very young age and mostly on the advice of their parents. The majority of patients wanted to remove the tattoos because of religious reasons. The Q-switched ruby laser seems to be highly effective in removing amateur blue-black tattoos in patients with colored skin.

Long-term results of split-skin grafting in combination with excimer laser for stable vitiligo.

BACKGROUND: Some cases of focal or segmental vitiligo are refractory to medical treatment, and surgical management is the treatment of choice. Postsurgical exposure to ultraviolet B rays can lead to faster and better cosmetic results. OBJECTIVE: To determine the long-term results of combination therapy with split-skin-thickness grafting and 308-nm excimer laser for the management of stable focal or segmental vitiligo. PATIENTS AND METHODS: Seventeen patients (8 female, 9 male) with stable focal or segmental vitiligo not responding to nonsurgical modalities were treated with split-skin-thickness grafting and postgrafting with 32 sessions of 308-nm excimer laser, beginning 2 weeks after surgery. The patients were followed up every year for evaluation of results. RESULTS: All seventeen (100%) patients showed repigmentation, and overall results were graded as excellent in 12 patients and good in the other five at the end of excimer laser therapy. Final evaluation done at the end of 1 year revealed excellent results in all 17 patients. Two patients developed new vitiligo lesion on other parts of the body during follow-up. None of the patients developed depigmentation of the transplanted skin. CONCLUSION: Combination treatment with split-skin-thickness grafting and postsurgical exposure to 308-nm excimer laser in patients with stable focal or segmental vitiligo can lead to fast, cosmetically good, long-lasting results.

Tropical medicine rounds: Treatment of Old World cutaneous leishmaniasis with dapsone, itraconazole, cryotherapy, and imiquimod, alone and in combination.

BACKGROUND: Cutaneous leishmaniasis (CL) is a major public health problem. The currently available therapies are expensive, not freely available, toxic, and not always curative. A simple, effective, noninvasive therapeutic approach is required for the treatment of CL. AIMS: To determine the clinical patterns of CL and to report our experience in the management of CL. METHODS: One hundred and ten patients with CL seen between January 2005 and December 2007 were included in this study. The diagnosis was based on clinical features, parasitologic diagnosis, histopathology, and culture. Each patient was treated according to disease severity with either topical (cryotherapy or imiquimod) or systemic (itraconazole or dapsone) monotherapy, or a combination of these modalities. RESULTS: CL was more common in adult expatriate men, with the upper limbs as the most commonly affected site. Noduloulcerative CL was the most common presentation (84.6%). Atypical CL was found in 18 patients. Skin biopsy was the most common diagnostic technique (66.6%). Monotherapy showed an overall success rate of 56.41%, whereas combination therapy was successful in 69.56% of cases. Cryotherapy alone was successful in 68.18% of cases. Imiquimod alone was ineffective. CONCLUSION: A stepwise approach represents a rational and practical way of confirming CL. A combination of itraconazole/dapsone and topically applied imiquimod is safe, simple, and effective for the treatment of CL. More studies are needed to establish the role of such an approach. Cryotherapy is also safe, simple and effective for the treatment of CL.

What is the appropriate duration of a therapeutic trial in cutaneous tuberculosis? Further observations.

BACKGROUND: Laboratory tests for the diagnosis of cutaneous tuberculosis lack adequate sensitivity and specificity and a trial of therapy is often used as a diagnostic test in difficult cases. However, the duration for which the trial should be undertaken is not clearly defined. Our previous study indicated that one month of therapy was adequate to detect a clinical response to treatment. However, about half the patients first reported after one month of treatment, some much later. METHOD: We therefore analysed the treatment records of 107 patients who received four-drug, short course, antitubercular therapy for a diagnosis of cutaneous tuberculosis in our hospital and who were asked to return for follow-up at biweekly intervals in the first month of treatment. RESULT: Twenty-one patients did not return for any follow-up visit, nine patients did not respond to treatment and treatment was stopped in one patient. Of the remaining 76 patients, 72 patients were recorded to have distinct clinical improvement within five weeks of starting treatment while only four patients showed improvement after 60-123 (8-17 weeks) days of therapy. CONCLUSION: These findings indicate that five weeks appears to be an adequate duration of a therapeutic trial in patients suspected to have cutaneous tuberculosis, with the exception of tuberculids and patients showing minimal clinical activity before treatment. Patients who have not responded by this time are unlikely to do so with further treatment and should have their diagnosis reviewed.

Treatment of parthenium dermatitis with methotrexate.

Patients with parthenium dermatitis are often unresponsive to topical steroids, and immunosuppressive agents may be necessary to reduce their need for systemic corticosteroids. We evaluated the efficacy of methotrexate in parthenium dermatitis. Sixteen patients unresponsive to topical treatment were included after baseline investigations, and treated with oral methotrexate (15 mg/week). Clinical response was monitored using a dermatitis area and severity index (DASI). Seven patients completed >or=6 months' follow-up, and their mean DASI fell to 5, 2.7 and 2.1 at the end of 1, 3 and 6 months respectively, from a baseline score of 10. Only 3/7 patients required oral prednisolone in the initial 2-4 weeks. Side effects were minor, being mainly folliculitis and furuncles. Methotrexate may hence be a useful alternative for patients with severe parthenium dermatitis.

Nail changes in childhood psoriasis: a study from Kuwait.

Psoriasis is a widespread skin disorder in which nail involvement can be seen in up to two-thirds of those affected. Childhood psoriasis is a distinct entity and the literature focused on nail changes associated with childhood psoriasis is scant. Our objectives were to evaluate the frequency of nail involvement in childhood psoriatic patients, assess the types of nail changes in childhood psoriasis, and compare our clinical findings with the few reports available in the literature. Two hundred and one consecutive new patients with childhood (age < or = 16 years) psoriasis of both sexes were selected for the study of nail changes. The diagnosis of psoriasis was made on clinical grounds. Each patient underwent a thorough dermatologic examination with special attention paid to the nail changes. If a clinical suspicion of fungal infection of the nails existed, further mycologic investigations were performed. We found the prevalence of nail changes to be 37.81% (boys > girls) in children who had psoriasis. Nail pitting was found to be the most common manifestation (61.84%) followed by onycholysis (30.26%), subungual hyperkeratosis (13.16%), and discoloration of the nail plate (7.90%). Nail involvement had no relationship to the type of psoriasis, patient's sex, or duration or extent of disease.

Comparison of minipunch grafting versus split-skin grafting in chronic stable vitiligo.

BACKGROUND: Minipunch grafting (MPG) and split-skin grafting (SSG) are common outpatient procedures for the surgical treatment of chronic stable vitiligo. However, there is a paucity of literature comparing the two procedures by the same group of investigators. OBJECTIVE: To compare the two techniques in patients with chronic stable localized vitiligo. METHODS: Sixty-four patients with stable vitiligo of 6 months duration were randomized into two groups to be taken up for MPG or SSG in a representative patch followed by PUVAsol therapy for 3 months. They were evaluated 3 months postoperatively for the degree of repigmentation and side effects. RESULTS: In the MPG group, 644 grafts, 2.5 mm in size, were placed on a total vitiliginous area of 521.25 cm2, whereas in the SSG group, 153 grafts covered a 1,489 cm2 recipient area. Three months postoperatively, in the first group, 15 cases (44.1%) showed very good to excellent (> 75%) repigmentation compared with 25 cases (83.3%) in group 2. Following MPG, 81 grafts (12.57%) were rejected. Cobblestoning was the main side effect, occurring in 13 cases (38.23%), and a variegated appearance was observed in 7 (20.58%) patients. The complications noted after SSG were achromic fissuring in four (13.3%) cases, graft contracture in four grafts (2.61%) in three patients, and rejection of seven grafts (4.57%) in one case; tire-pattern appearance in two patients (6.6%); milia formation in four (13.3%) patients; and depigmentation of the grafts in two (6.6%) cases. In both groups, superficial scarring was noted at the donor site in all cases, whereas hypertrophic scarring occurred in 3 (10%) patients after SSG. CONCLUSION: SSG carries a distinct advantage over MPG in producing excellent cosmetic matching over larger areas using fewer grafts, especially over the face and extremities.

Failure of titer of contact hypersensitivity to correlate with clinical severity and therapeutic response in contact dermatitis caused by parthenium.

BACKGROUND: The titer of contact hypersensitivity (TCH) has been used to determine the degree of contact hypersensitivity in patients with contact dermatitis. The values have been found to vary in different individuals and also in the same individual at different times apparently due to the varying severity of the disease. We evaluated the correlation of TCH with disease severity and therapeutic response in patients of contact dermatitis caused by the plant Parthenium hysterophorus. METHODS: Forty-two patients, 30 (71.4%) males and 12 (28.6%) females, aged between 30-75 years, having air-borne contact dermatitis to Parthenium hysterophorus for 0.5-20 years were included in the study. The disease severity and TCH at baseline were recorded in all the patients. They were treated with azathioprine and followed up every month for 4-69 months. The TCH was repeated every 3 months and the last recorded TCH value was taken for analysis in each patient. RESULTS: The baseline clinical severity score (CSS) varied from 10-80 (mean +/- SD: 35.47 +/- 19.41) in these patients. It ranged from 10-30 in 22 (52.4%) patients, from 31-50 in 14 (33.3%) patients, and was more than 50 in 6 (14.3%) patients. The baseline TCH to Parthenium was undiluted (UD) in 2 (4.8%), 1:10 in 15 (35.7%), 1:100 in 20 (47.6%), and 1:1000 in 5 (11.9%) patients respectively. At the end of the study, the clinical severity of the disease decreased in most of the patients. The CSS came down to 0 in 31 patients, to 10-20, and to 50 in 4 patients each, but remained stable in three patients who had baseline CSS from 20-40. The overall mean CSS came down from 35.47 +/- 19.41 to 4.76 +/- 9.43 (p = 0.002). However, there was no significant change in the TCH levels over time (p = 0.153). The last TCH value was negative in 2 (4.8%) patients, undiluted in 5 (11.9%), 1:10 in 10 (23.8%), 1:100 in 18 (42.9%), and 1:1000 in 7 (16.7%) patients. There was no change in the TCH values in 16 (38.1%) patients while it increased or decreased by 1-2 dilutions in 12 (28.6%) patients each. CONCLUSIONS: We therefore conclude that the TCH does not correlate with the clinical severity of contact dermatitis or response to treatment.