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.

Randomized control trial to study the efficacy and safety of platelet-rich plasma as intraoperative holding solution in hair restoration surgery: A pilot study.

Background: Hair restoration surgery is a definitive surgical procedure undertaken for androgenetic alopecia (AGA). Platelet-rich plasma (PRP) therapy has gained importance in recent times as a valuable adjunct to therapy in hair restoration. However, the various beneficial effects of PRP as intraoperative holding solution hair restoration surgery remain to be objectively defined. Methods: Twenty cases of AGA were allocated into two groups (PRP and non-PRP). The follicular grafts harvested were stored in platelet-rich plasma/chilled ringers lactate solution depending on subject/control and were implanted in receding hairline using hair implanters. Patients were reviewed at the end of 2 weeks, 4 weeks, 8 weeks, 3 months, and 6 months using clinical and folliculoscopic images. The analysis was performed using SPSS version 20.0. Results: Follicular growth as assessed using the percentage of grafts in actively growing phase posttransplant showed faster recovery from 'shock effluvium' in the PRP group when compared with the non-PRP group from Week 4, through Week 8 and 3 months with the 'lead' increases of percentage growth difference being statistically significant(P = 0.02) between the two groups. At the end of 6 months, 100% of patients recorded a hair shaft length of >10 mm in the PRP group, whereas only 20% achieved >10 mm length. The difference in hair densities between PRP and the non-PRP group from 4 weeks up to 6 months in the non PRP group remained significant (P < 0.05). Conclusion: Intraoperative PRP as a holding solution improves outcome in hair restoration surgery by a significant improvement in the mean density of the implanted follicular unit grafts at 6 months.

Comparative study of the efficacy and safety of two grafting procedures (an automated epidermal harvesting system and non-cultured epidermal cell suspension) in the treatment of stable vitiligo.

Background The non-cultured epidermal cell suspension method is a well-established but tedious grafting modality in the management of stable vitiligo. Recently a more user-friendly automated epidermal harvesting system has been introduced. Aim This was a pilot study to compare the efficacy and safety outcomes of the above two grafting procedures. Study design The study was a single-blinded split-body randomised controlled trial. After scientific and ethical clearance, the trial was registered with CTRI (CTRI/2018/05/014225). Thirty consenting patients of stable vitiligo with 60 near-symmetrical patches were recruited. Block randomisation was done using computer-generated randomisation software and each patch was allocated either of the two grafting modalities. Efficacy was assessed by the Physician Global Assessment Scale on serial images and pain by the Numerical Rating Pain Scale. Results and conclusion The non-cultured epidermal cell suspension was found to be an overall statistically superior technique to the automated epidermal harvesting system in terms of efficacy (re-pigmentation). Both donor and recipient site complications were significantly less with the automated epidermal harvesting system grafting and this method had the distinct advantage of being a painless and easy technique with minimal recovery time. A novel observation was that a good colour match and near-complete re-pigmentation occurred in patients with a darker skin colour with both techniques. Limitations The main limitation of our study was the small sample size. Also, the size of the treated patches was limited such that they could be covered by the 5 × 5 cm size of the automated epidermal harvesting system blade. However, a larger area can be covered with multiple sessions.

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.

An atypical presentation of toxic epidermal necrolysis without mucosal involvement.

Toxic epidermal necrolysis (TEN) is a severe adverse cutaneous drug reaction with ubiquitous involvement of mucosa. Drugs are identified as the main etiology in most cases. Cutaneous involvement in TEN occurs in the form of widespread painful erythematous macules, targetoid lesions, full-thickness or focal epidermal necrosis, whereas mucosal involvement involves oral, genital, and ocular mucous membranes along with preceding prodromal flu-like symptoms. Atypical presentations include involvement of only mucosa without involvement of skin. We report a rare case of TEN without any mucosal involvement.

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.

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.

Are we witnessing a paradigm shift in leprosy: Two atypical presentations of histoid hansen's disease.

Hansen's disease is a chronic infectious granulomatous disease with varied clinical presentation. In the postelimination era, histoid Hansen's disease is an important emerging lepromatous subset known to mimic varied dermatoses, thereby making clinical diagnosis difficult and often delayed. We report two cases of histoid Hansen's disease bereft of clinical cardinal signs of leprosy.

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.

Immune-mediated tuberculous uveitis - A rare association with papulonecrotic tuberculid.

The tuberculids are a group of distinct clinicopathological form of skin lesions representing hypersensitivity reaction to hematogenous dissemination of Mycobacterium tuberculosis or its antigen from an underlying active or a silent focus of tuberculosis elsewhere in the body in an individual with a strong antituberculous cell-mediated immunity and by definition do not show bacilli on special stains and are culture-negative. Ocular involvement can occur in tuberculosis, both due to direct invasion by the bacilli as well as an immune-mediated reaction; however, immune-mediated tuberculous uveitis occurring as a hypersensitivity response in association with PNT has hardly been reported in the literature. Here we report one such rare case.

A dissimulate presentation of histoid Hansen's disease in the form of erythema nodosum leprosum.

Hansen's disease is a chronic infectious granulomatous disease with varied clinical presentation. Histoid Hansen's disease is an important emerging lepromatous subset of Hansen's disease known to mimic varied dermatoses. Occurrence of reactions, especially erythema nodosum leprosum (ENL), is rare in this form of leprosy. We report a case of Histoid Hansen's disease with initial presentation of ENL while undergoing management for infertility.

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.