Dermoscopy of Oral Mucosal Lesions: Experience from a Tertiary Care Center in North India and Review of Literature.

Background: Patients with mucosal lesions form a significant number of routine outpatients presenting to the dermatology department where diagnostic confirmation using histopathological examination of mucosal biopsy is neither feasible nor warranted in every patient. Objective: To study the dermoscopic features of various mucosal lesions affecting the oral cavity and to assess the reliability of mucoscopy vis-a-vis clinico-laboratory findings. Materials and Methods: An observational, cross-sectional, hospital-based study was conducted over a period of 2 years from March 2019 to February 2021 in the dermatology outpatient department. Patients presenting with oral mucosal lesions, with or without associated cutaneous involvement, were recruited for mucoscopic evaluation after taking an informed written consent. A detailed history and clinical examination, with emphasis on mucocutaneous examination, was performed and findings were recorded on a standard predesigned proforma. Mucoscopy of oral mucosa was carried out using a handheld dermoscope as well as Universal Serial Bus connected video-dermoscope in both nonpolarized and polarized modes. The different mucoscopic features were seen at these sites, compared with each other, analyzed and findings were recorded. A diagnosis was made on the basis of mucoscopic findings and correlated with clinical diagnosis. The data was analyzed using appropriate statistical tests. Results: The mean age of patients was 34.3 years and the mean lesional duration was 68.2 weeks. Oral lichen planus (18.66%) was the most common disorder studied, followed by recurrent apthous stomatitis (16.00%), pigmentary lesions (12.66%), vascular disorders (12.00%), mucocele (5.33%), pemphigus vulgaris (4.66%), and discoid lupus erythematosus (4.66%). Conclusion: Dermoscopy in oral lesions facilitates the visualization of the mucosal surface and provides quick confirmation of diagnosis in various mucosal disorders with advanced diagnostic accuracy. Mucoscopy was found helpful in differentiating the oral ulcers, which are a presenting feature of various serious mucocutaneous disorders. Mucoscopy could be a helpful aid in diagnosing pigmented skin lesions and alleviating the apprehension regarding oral melanoma and serve as a screening tool in case of squamous cell carcinoma lips. Limitations: Confirmatory histopathological analysis and correlation with mucoscopic findings could not be established in our study.

Prevalence and Pattern of Dermatological Manifestations Among Substance Users Across Kashmir Valley in North India.

Background: Substance use has turned out to be one of the growing social problems of the present society cutting across all sorts of boundaries of the world with Kashmir Valley being no exception to this growing pathological phenomenon. Aims and Objectives: To find the prevalence and pattern of dermatological manifestations among substance users across Kashmir Valley. Materials and Methods: Cross-sectional study where patients of all age-groups, irrespective of gender, were enrolled in the three largest districts of Kashmir Valley over a span of 18 months. Results: Sample size was 710 with a male/female ratio of 12.4:1. The mean age of the cases was 25.2 ± 7.05 years. Heroin, one of the opioids, was the most common substance used (n = 515), followed by cannabis (n = 334). Pruritus was found to be the most common dermatological manifestation overall and statistically significant among heroin users. Stigmata of injection drug use (IDU) with the presence of track marks and sooting tattoos (93.1%), atrophic scars secondary to skin popping (30.7%), active skin ulcers (18.8%), and puffy hand syndrome (8.7%) were specifically seen among injection drug users. Oral involvement was seen in 48.5%, including periodontal disease, oral thrush, and stomatitis nicotinica. Hyperhidrosis was present in 30%, and hesitation cuts over arms in 16.3% of all substance users. Conclusion: Dermatological manifestations are quite prevalent among substance users in the population of Kashmir. Pruritus with temporal relation to substance use, stigmata of injectable drug use including track marks and sooting tattoos, atrophic scars at injection sites, active skin ulcers, and skin and soft tissue infections, and hyperhidrosis are among important dermatological clues for detecting substance use. Recognition of such cutaneous signs is important in these cases for more effective diagnosis and treatment.

Efficacy of Fractional CO2 Laser for Improvement of Limited Mouth Opening in Systemic Sclerosis.

Background: Systemic sclerosis is a multisystem auto-inflammatory disease-causing fibrosis in the skin and internal organs. A frequent complication of systemic sclerosis is the limited mouth opening (LMO), a difficult-to-treat condition with only a few treatment options available. Aims and Objectives: The aim of this study was to evaluate the response of fractional carbon dioxide (CO2) laser resurfacing in LMO associated with systemic sclerosis. Materials and Methods: This was a hospital-based prospective study in which diagnosed cases of systemic sclerosis were taken. Patients who had significant LMO and who gave informed consent were included in the study. Fractional CO2 laser treatment was performed in the perioral area. Patients were assessed at baseline, after three and six sessions, and 3 months after the last session. Assessment was done by measurement of the interincisor distance (IID) using a ruler and calculation of the mouth handicap in systemic sclerosis (MHISS) scale. Results: Improvement in IID occurred 3 months after the first session with a mean gain of +5 mm (range 2-7). At 6 months, a mean gain of +8.5 mm (range 7-10) in IID was observed (P < 0.001). The MHISS score decreased by a mean of 14 (range 11-17) (P < 0.001). All patients showed improvement of mouth opening, which allowed the patients to have better phonation and the patients were able to have proper dental care posttreatment in the form of brushing of teeth and other dental procedures. The adverse effects noted in these patients included erythema that resolved spontaneously or after icing posttreatment. Other adverse effects noted were stinging and burning sensations that were mild and transient. Conclusion: Fractional CO2 laser forms a safe, effective, and well-tolerated treatment modality for improvement of LMO in systemic sclerosis. Limitations: The limitations of this study were less number of patients and no long-term follow-up.

Pediatric Cutaneous Leishmaniasis: A Clinico-Epidemiological Study from North India.

BACKGROUND: There has been an upsurge in the cases of cutaneous leishmaniasis over the past few years in the pediatric population of Jammu and Kashmir, hitherto a nonendemic area for the disease., The aim of this study was to describe the clinico-epidemiological profile and therapeutic outcome of pediatric cutaneous leishmaniasis (PCL) over a 10-year period in J and K. MATERIALS AND METHODS: An observational study was conducted at two tertiary care hospitals of Jammu and Kashmir over a period of 10 years (July 2010-June 20). Children presenting to the outpatient department with lesions suggestive of CL were enrolled. Patients suspected of having CL based on clinical criteria were subjected to slit skin smears (SSS) and histopathological examination (HPE) for validation of the diagnosis. Intralesional or systemic sodium stibogluconate (SSG) was the treatment modality used for the management of patients. Clinical follow-up was done at intervals of 2 weeks for the first 2 months and monthly thereafter. RESULTS: A total of 376 cases of CL in children aged 1.5-15 years (mean age 8.4 ± 1.4 years) were included in the study. The duration of the disease ranged from 8 to 52 weeks (mean 22.52 ± 1.5 weeks). Lesions were noted mainly on exposed parts of the body, with face being the most commonly affected site (89.0%). Nodulo-ulcerative plaques were the predominant clinical presentation (62.76%). The diagnosis was confirmed by the demonstration of Leishman Donovan (LD) bodies in 54.25% on SSS- and 25.79% on hematoxylin and eosin -stained tissue sections. In cases where diagnosis could not be confirmed by demonstration of LD body, a histological pattern conforming to CL and response to a therapeutic trial of SSG provided evidence of leishmanial infection. Complete healing was achieved in 95.02% of the cases at the end of treatment. CONCLUSION: CL is an emerging health problem in the pediatric population of Jammu and Kashmir. Awareness among pediatric health workers regarding this disease and recognition among the differential diagnosis of ulcerated papules or plaques in the pediatric population is imperative.

Candidal Onychomycosis: Clinicoepidemiological Profile, Prevailing Strains, and Antifungal Susceptibility Pattern-A Study from a Tertiary Care Hospital.

BACKGROUND: Despite an increasing trend of onychomycosis caused by Candida species in recent years, there is a scarcity of published data. OBJECTIVE: To determine the epidemiological and clinical characteristics of Candida onychomycosis, to identify the prevalent, and perform in-vitro antifungal susceptibility testing (AFST) of the isolates. METHODOLOGY: A total of 506 consecutive patients with a clinical suspicion of onychomycosis were included in a cross-sectional clinical study. Nail scrapings and clippings were subjected to KOH examination and culture. Species identification and antifungal drug sensitivity testing were done for Candida isolates using Vitek 2YST Compact system using Vitek 2 cards. RESULTS: Out of 384 (75.88%) culture-positive cases, dermatophytes were isolated in 58.08%, yeast in 26.30%, and NDM in 12.24%. Of the yeast, Candida albicans was isolated in 59.4% and non-albicans species in 40.59%. AFST showed that most of Candida species exhibited 100% susceptibility to most of the antifungal drugs tested, while intermediate resistance to fluconazole and flucytosine was seen in some non-albicans species (C. krusei, C. glabrata, and C. guilliermondii). Time taken for species identification was 14-18 h (average 15.5 h), while determination of minimum inhibitory concentration took 9-27 h (average 13 h). CONCLUSIONS: Our study showcases the present scenario of Candida distribution and the resistance patterns of various species afflicting the nail unit. Furthermore, our findings clearly indicate that the carriage of this pathogenic yeast is seen in both healthy individuals as well as with immunosuppression.

Clinical and epidemiological study of cutaneous leishmaniasis in two tertiary care hospitals of Jammu and Kashmir: An emerging disease in North India.

BACKGROUND: An increasing number of patients with cutaneous leishmaniasis (CL) are reporting to tertiary care centers in Jammu and Kashmir, an area that has previously been non-endemic for this disease. This merits consideration of CL as a major health problem of considerable epidemiological importance. The aims of this study were firstly to describe the clinico-epidemiological profile, therapeutic characteristics, and outcomes of patients with CL and secondly to highlight this union territory as a new focus of endemicity for CL. METHODS: A two-center hospital-based prospective cohort study was conducted at two tertiary care hospitals in Jammu and Kashmir over a period of 10 years (July 2009 to June 19). All patients presenting to the outpatient departments with lesions suggestive of CL were enrolled for the purpose of this study. Demographic data were recorded on a proforma questionnaire, along with a detailed history and the results of a meticulous examination. Patients diagnosed with CL based on clinical criteria were subjected to slit skin smear (SSS) and histopathological examination for confirmation of the diagnosis. An intralesional pentavalent antimonial, sodium stibogluconate (SSG), was administered at a dose of 0.5 mL/cm2 (100 mg/mL solution) three times weekly to those patients with smaller lesions, and intravenously or intramuscularly at a dose of 20 mg/kg/day to those with larger lesions. The response to treatment was assessed by total re-epithelialization of the lesion and an absence of infiltration and erythema, with or without scarring. Treatment was given until complete resolution of the lesions or for a maximum duration of 10 weeks when given intralesionally and 3 weeks when given systemically. Clinical follow-up was performed twice weekly for the first 2 months and monthly thereafter. The final response to treatment was assessed at 6 months. RESULTS: The study included a total of 1300 patients with a mean age of 26.7 ± 18.5 years. The mean duration of the disease was 28.52 ± 13.5 weeks, ranging from 8 to 64 weeks. Lesions were noted mainly on exposed parts of the body, with the face being the most commonly affected site (89.00%). Nodulo-ulcerative plaques were the predominant lesion type observed (73.92%). The presence of Leishman-Donovan bodies could be demonstrated on SSS and histopathology in 60.69% and 39.54% of patients, respectively. The presence of a recognizable histological pattern conforming to CL and a response to a therapeutic trial of SSG was considered to be confirmatory in the remaining patients. Complete cure was achieved in 84.23% of cases during the study period. Single lesions were more likely to respond to treatment as compared to multiple lesions. The route of administration did not have any significant impact on the final outcome. CONCLUSIONS: With the disease showing an escalating trend in Jammu and Kashmir, the possibility of a new focus of endemicity and its impact on public health need to be contemplated, and appropriate measures should be initiated to contain its spread.

Clinicoepidemiological and Patch Test Profile of Patients Attending the Contact Dermatitis Clinic of a Tertiary Care Hospital in North India: A 7-Year Retrospective Study.

INTRODUCTION: Allergic contact dermatitis (ACD) is a growing concern due to increased use of cosmetics and topical medications routinely and exposure to a large number of allergens on day-to-day basis. Patch testing is a reliable method for detecting the causative antigens in suspected cases. AIMS AND OBJECTIVES: To assess the demographic profile, pattern of ACD, and patch test profile of suspected cases of ACD attending contact dermatitis clinic of our department. MATERIALS AND METHODS: It was a retrospective study in which all the data enrolled in the contact dermatitis clinic of our department over a 7-year period were analyzed. Patch testing was done using the Indian Standard Series of 20 antigens primarily, and other batteries were used depending on patient requirement and availability. RESULTS: A total of 582 patients were enrolled in the contact dermatitis clinic over a period of 7 years. Hand eczema was the most common pattern seen in 268 cases followed by feet eczema, hand and foot eczema, facial eczema, forearm and leg eczema and photoallergic contact eczema. A total of 177 patients (30.4%) gave positive patch test results, with nickel sulfate being the most common allergen identified followed by potassium dichromate, cobalt sulfate, paraphenylenediamine, neomycin sulfate, and fragrance mix. CONCLUSION: Common allergens identified in our study were more or less similar to studies from other parts of India. However, due to the unique climate of the valley, the profile of parthenium sensitivity was low in our study when compared to the rest of the country.

Chronic Relapsing Cutaneous Leishmaniasis in an Elderly Female: A Rare Clinical Presentation from a Nonendemic Area.

The presentation of cutaneous leishmaniasis (CL) varies from asymptomatic erythematous papules to nodulo-ulcerative forms over the exposed parts of body, generally healing slowly in 3-12 months. Besides, rare and atypical presentations of disease are being reported that pose both a diagnostic and therapeutic challenge especially in nonendemic areas. There has been an increase in the incidence of CL in our region over the past decade, and most of our patients belong to district Kupwara which is the north-most district of Kashmir valley, situated at an altitude of 5300 feet above sea level sharing borders with Pakistan-administered Kashmir. Herein, we report a case of an elderly female from a nonendemic area who had a relapse of cutaneous disease at a previously treated site and came to us with an atypical presentation of more than 2 years duration.

Serum Levels of 25-hydroxyvitamin D in Chronic Urticaria and its Association with Disease Activity: A Case Control Study.

AIM: To evaluate the relationship between vitamin D levels and chronic spontaneous urticaria (CSU) and compare with healthy age and sex matched controls. MATERIAL AND METHODS: This was a hospital-based cross-sectional study conducted over a period of 1 year, in which 110 patients with CSU were recruited along with an equal number of sex and age-matched healthy controls. For each patient, urticaria activity score (UAS) was calculated and autologous serum skin test (ASST) was performed. Plasma 25-hydroxyvitamin D [25-(OH)D] was analyzed by chemiluminescence method. A deficiency in vitamin D was defined as serum 25-(OH)D concentrations <30 ng/mL. The statistical analysis was carried out by using appropriate statistical tests. RESULTS: The mean serum 25-(OH)D levels of CSU patients was 19.6 ± 6.9 ng/mL, whereas in control group, the mean level was 38.5 ± 6.7, the difference being statistically significant (P < 0.001). A significant negative correlation was found between vitamin D levels and UAS. (P < 0.001). The number of patients with ASST positivity was 44 (40%). CONCLUSION: The patients with CSU had reduced levels of vitamin D when compared to healthy controls. Furthermore, there was a significant negative correlation between the levels of serum vitamin D and severity of CSU.

Epidemiological profile of pediatric ocular trauma in a tertiary hospital of northern India.

PURPOSE: Ocular trauma is one of the most common causes of acquired blindness in children. It measures about 8%-14% of total childhood injuries. This study aims to determine the epidemiological profile of ocular trauma in the pediatric age group attending a tertiary hospital in northern India. METHODS: A retrospective study was conducted in our hospital between June 2014 to July 2015 and all the children aged 0-16 years presenting with ocular trauma in eye outpatient department and emergency were enrolled in the study. Various epidemiological parameters like age, sex distribution, duration of presentation, mode of injury, type of injury and final visual outcome were analyzed. RESULTS: Of total 357 patients, 271 (76%) were below the age of 12 years; 41.1% of children with ocular trauma belonged to age group 2-6 years. The male to female ratio was 2.9:1. Out of total patients, 242 (67.8%) presented with closed globe injury. Among the closed globe injury, the history of fall was present in about 35% of children, followed by trauma while playing with bat/ball (15.7%) and finger nail trauma (13.2%). Among open globe injury, trauma with needle, knife, glass and pen were common causes. Home was the most common place of injury (47.8%), followed by streets (17.9%) and playground (14.9%). CONCLUSION: Children are vulnerable to ocular trauma and need more supervision. Sharp objects like needles, knives, household chemicals like acids should be out of reach of children.

Treatment of post-burn and post-traumatic atrophic scars with fractional CO2 laser: experience at a tertiary care centre.

Scars are abnormal wound responses in predisposed individuals. They occur after any kind of wound and skin inflammation in predisposed individuals. Despite their benign nature, they can be aesthetically disabling. Although several approaches have been tried in their management, most of them have produced poor results. This study aims to assess the efficacy and safety of fractional CO2 laser treatment in the management of post-burn and post-traumatic scars. One hundred consecutive patients (77 females and 23 males) affected by post-burn scars as well as post-traumatic atrophic scars were treated with monthly sessions of fractional CO2 laser treatment. Patient's response to treatment was assessed clinically as well as improvement of scars by comparing the photographs taken before treatment with those taken 6 months after the last treatment session. Changes in skin texture, surface irregularity and pigmentation were assessed on a quartile grading scale and scored individually from 0 to 4. A mean of the three individual scores was calculated and the response was labelled as 'excellent' if the mean score achieved was > 3. A score of 2-3 was labelled as good response while a score below 1 was labelled as 'poor' response. A mean of six treatments per scar were required and all patients, followed up for 1 year after the last treatment, had optimum results and no recurrence. Response to treatment was excellent in 53.75%, good in 16.25% patients, and poor in 30% patients. Fractional CO2 laser gives a very good result in the management of patients with post-burn scars as well as post-traumatic scars with minimal adverse effects.

Contact dermatitis caused by tulips: identification of contact sensitizers in tulip workers of Kashmir Valley in North India.

BACKGROUND: Tulip, belonging to the genus Tulipa and family Liliaceae, is a spring-blooming perennial that grows from bulbs. Owing to manual handling, contact dermatitis can occur in professionals at any stage of the growth cycle of the tulip plant. OBJECTIVES: To determine the clinical pattern of contact dermatitis resulting from tulip plant cultivation, and to assess contact allergy in workers coming into contact with this plant. METHODS: One hundred and sixty-four tulip workers were screened, and 48 patients with suspected contact dermatitis were patch tested with 39 allergens, including haptens from the Indian baseline series, a plant series, and extracts from different parts of the tulip plant. RESULTS: Thirty-nine positive patch test reactions were observed in 21 patients. Seventeen patients showed positive reactions to either α-methylene-γ-butyrolactone or to tulip plant extract. Clinical relevance was observed for 13 of 17 positive patch test reactions. CONCLUSIONS: Contact dermatitis is an important health hazard in workers dealing with tulip bulbs. Further studies to identify and isolate other possible tulip allergens, and to quantify the amounts of allergens in different parts of the tulip plant, are recommended.

Erythromelanosis Follicularis Faciei et Colli - A Cross-sectional, Descriptive study.

BACKGROUND: Erythromelanosis follicularis faciei et colli (EFFC) has always been reported as a rare disorder, and more data are needed to define its etiology and epidemiology. OBJECTIVES: To present a descriptive study of this disorder from Kashmir and present a review of literature on the same. MATERIALS AND METHODS: A cross-sectional, descriptive study was conducted on 14 patients with clinical lesions suggestive of EFFC, presenting to our dermatology outpatient clinic between May 2013 and April 2015. After obtaining informed consent from all patients, the demographic and clinical data were collected and punch biopsies were taken which after being fixed in formalin were stained for hematoxylin and eosin. The study was approved by Institutional Review Board. RESULTS: Age of the patients ranged from 12 to 35 years with a mean age of 24.8 years. Females outnumbered males in a ratio of 1.3:1. Family history was positive in one case, and one patient had unilateral presentation. The classical triad of erythema, pigmentation, and follicular papules were present in 100% patients. Telangiectasias were observed in 28.57% patients only. Classical sites described were involved in all the cases (100%). In addition, lesions were found to involve eyebrows (28.57%), forehead (28.57%), upper lips (14.28%), and pinna (21.42%). Keratosis pilaris was present in all patients (100%); most common sites affected were upper arms and thighs. Two (14.28%) had generalized distribution. Histopathology in all correlated well with clinical findings. CONCLUSION: EFFC has always been reported as a rare disorder, but we believe that it is not so. The reason could be either lack of awareness of the disease by the patient due to its generally asymptomatic nature or under-recognition by the physicians. Awareness about the disease on part of dermatologist and recognition of clinical presentation is important for correct diagnosis and to help find more effective therapeutic modalities.