Linear trends over 20 years in sexually transmitted infections among patients attending a tertiary care centre in north Kerala, India.

BACKGROUND: Worldwide, a declining trend is observed in sexually transmitted infections of bacterial origin which is reflected as a rise in the proportion of viral sexually transmitted infections. AIMS: To find out the clinical referral patterns of sexually transmitted infections among patients who attended the sexually transmitted infection clinic attached to Dermatology and Venereology Department of Government Medical College, Kozhikode from 1.1.1998 to 31.12.2017 and to study the linear trends in the pattern of sexually transmitted infections over 20 years. METHODS: After clearance from the institutional ethics committee, a retrospective study was conducted among patients who attended the sexually transmitted infection clinic of Government Medical College, Kozhikode from 1.1.1998 to 31.12.2017 and were diagnosed to have sexually transmitted infections. RESULTS: During the 20 year study period 5227 patients, attended the sexually transmitted infection clinic of our institution. Diagnosis of sexually transmitted infection was made in 2470 (47.3%) cases. Predominant sexually transmitted infections were herpes genitalis (964, 39%), condyloma acuminata (921, 37.9%) and syphilis (418, 17.2%). Viral sexually transmitted infections (1885, 76.3%) outnumbered bacterial sexually transmitted infections (575, 23.3%). A declining trend was noted for both bacterial and viral sexually transmitted infections over the 20 year period, which was more marked for the former. But the latter years of the study documented a rising trend in total sexually transmitted infections including bacterial sexually transmitted infections. LIMITATIONS: The study does not reflect the status of sexually transmitted infections in the general population since it was conducted in a tertiary referral center. CONCLUSION: The disturbing ascending trend recorded in sexually transmitted infections including syphilis during the final years of the 20-year period needs to be watched closely, to plan future strategies.

Proposal for a Severity Score (DeASI, Dermatophytosis Area and Severity Index) for the Evaluation of Dermatophyte Infections - A Delphi Consensus Study.

Background: There has been a significant increase in the incidence of recurrent, resistant, and extensive dermatophyte infections worldwide recently. This menace has spurred the need for more well-designed randomized controlled trials to optimize the treatment of dermatophyte skin infections. One of the limitations in designing such studies is the limited availability of standard and validated score, to measure the severity of dermatophyte infections. Aims: To create a severity score for the evaluation of dermatophyte infections. Materials and Methods: A Delphi consensus model was used to frame a severity scoring tool for superficial dermatophyte skin infections. Fourteen experts participated in the first round and twelve experts participated in the second round. Results: Based on the expert consensus, a final scoring system proposed was: Final Severity Score (FSS) = Sum total of Body Surface Area (BSA) in hand units for each patch multiplied by the sum of the scores for pruritis (P), lichenification (L), and actively raised borders (A) for each patch (FSS = BSA in hand units × (P + E + L + A) of patch 1 + BSA in hand units × (P + E + A) of patch 2 …etc.). For measuring hand units more accurately fractional values of 0.25 can be used (0.25 corresponding to an approximate 1/4th of a hand unit). A score of +1 will be added in case of the following - 1) Close contact/family member affected, 2) History of at least one recurrence in the previous 6 months after a course of oral antifungals, 3) History of immunosuppression (on immunosuppressive medication or having underlying immunosuppressive disease). The scores will be valid only if the patient has not used any treatment topical or systemic, for at least 2 weeks before enrolment. Conclusion: The proposed Dermatophytosis Area and Severity Index (DeASI) score will help the physicians and researchers standardize the treatment protocol for dermatophytosis, henceforth, assessing the response to therapy. This will also help to standardize the parameters of effectiveness while designing any clinical trial.

Hypopigmented Skin Lesions with Doubtful/Minimal Sensory Impairment: A Histopathology-Based Analysis.

Background: Cardinal criteria proposed by the World Health Organisation (WHO) lack sensitivity to diagnose indeterminate leprosy. Aims: To estimate the frequency of hypopigmented skin lesions with doubtful/minimal sensory impairment showing histopathology features of indeterminate leprosy. To compare between the histopathology findings noted in specimens showing features suggestive of indeterminate leprosy and those showing a non-specific dermatitis pattern. Materials and Methods: Data on patients who attended our department with hypopigmented patches with doubtful/minimal sensory impairment from January 2018 to December 2019 and who underwent a skin biopsy were collected. A pathologist blinded to the clinical findings reviewed the histopathology specimens using a pre-set questionnaire. Results: We studied sixteen biopsy specimens from 14 patients. Eight specimens (50%) showed histopathology suggestive of indeterminate leprosy and the remaining eight showed a non-specific dermatitis pattern. A higher percentage of patients with indeterminate pattern showed mast cells (87.5% vs 25%) and fibrosis around nerve twig or sweat duct (75% vs 12.5%) when compared to those who showed a non-specific dermatitis pattern. Limitations: Small sample size and retrospective study design were the limitations. Conclusions: We found histopathology features of indeterminate leprosy in 50% of the skin biopsy specimens from hypopigmented lesions with doubtful/minimal sensory impairment. The present study highlights the need to improve the diagnostic definition of indeterminate leprosy.

Impact of Lockdown Restrictions on Treatment of Leprosy: A Retrospective Analysis.

Context: Coronavirus disease 2019 (COVID-19) has shown the potential to affect the life of people all over the world either directly or indirectly. Aim: To assess the impact of lockdown measures on treatment of leprosy among patients who received treatment from a tertiary referral centre. Settings and Design: A retrospective study was conducted at the dermatology department of a tertiary referral centre. Materials and Methods: We did a retrospective analysis of case records of patients with leprosy who received treatment from our tertiary referral centre from 01 March 2020 to 31 May 2021. Results: During the 15-month period, 59 patients received multi-drug therapy (MDT) for leprosy from our centre. Thirty-two patients (54.2%) were already receiving MDT as on March 2020, and 27 others (45.8%) were diagnosed with leprosy and started on MDT during the period from March 2020 to May 2021. Two patients (3.4%) developed COVID-19 while on MDT. When lockdown measures were implemented, 12 patients (12/59, 20.3%) discontinued treatment, citing conveyance difficulties. Three patients (3/59, 5.1%) were lost to follow-up. Limitations: Small sample size and reliance on retrospective data from a single centre were the major limitations of the study. Conclusion: A conscious effort is needed from healthcare professionals and the government to ensure that implementation of national programmes is not adversely affected by the ongoing COVID-19 pandemic.

Molecular epidemiology of enteroviruses associated with hand, foot, and mouth disease in South India from 2015 to 2017.

Hand, foot, and mouth disease (HFMD) is a common childhood infection caused by human enteroviruses and is clinically characterised by fever with vesicular rash on the hands, feet, and mouth. While enterovirus A71 (EV-A71) and coxsackievirus A16 (CVA16) were the major etiological agents of HFMD in India earlier, the data on recently circulating enteroviruses associated with HFMD are sparse. Here, we describe the molecular epidemiology of enteroviruses associated with HFMD in South India from 2015 to 2017. We used archived enterovirus real-time reverse transcription (RT) PCR-positive vesicle swab and/or throat swab specimens from clinically suspected HFMD cases collected from four secondary-care hospitals in South India between July 2015 and December 2017. PCR amplification and sequencing were done based on the 5'VP1, 3'VP1, VP2, or 5´NCR regions to identify enterovirus types. Genetic diversity among enteroviruses was inferred by phylogenetic analysis. Of the 107 enterovirus RNA real-time RT-PCR-positive HFMD cases, 69 (64%) were typed as CVA6, 16 (15%) were CVA16, and one (1%) was CVA10, whereas in 21 (20%) cases, the virus was not typeable by any of the methods used in the study. The majority of HFMD cases (89, 83%) were in children less than five years old, while 11 (10.3%) were in adults. 5'VP1 yielded the maximum number of enteroviruses genotyped, and phylogenetic analysis showed that the CVA6 strains belonged to subclade D3, while the subclades of CVA16 and CVA10 were B1c and D, respectively. The predominant etiological agent of HFMD in South India during 2015-2017 was CVA6, followed by CVA16 and CVA10.

RegiSCAR DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) Validation Scoring System and Japanese Consensus Group Criteria for Atypical Drug-Induced Hypersensitivity Syndrome (DiHS): A Comparative Analysis.

CONTEXT: Drug reaction with eosinphilia and systemic symptoms (DRESS) and drug-induced hypersensitivity syndrome (DiHS) represent the same spectrum of a drug reaction. AIMS: To compare the clinical profile of patients diagnosed as definite/probable DRESS by the Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) scoring system and as atypical DiHS by Japanese consensus group criteria. SETTINGS AND DESIGN: We did a retrospective study in a tertiary referral center. MATERIALS AND METHODS: We included patients who satisfied the criteria for definite/probable DRESS and/or atypical DiHS and who received inpatient care in our department from January 2011 to December 2018. We compared the clinical and laboratory findings in patients diagnosed by the two criteria. STATISTICAL ANALYSIS: Pearson Chi-square test was used to compare the proportion of patients with severe reactions diagnosed by the RegiSCAR DRESS validation scoring system and the Japanese consensus group criteria. RESULTS: Among the 390 case records reviewed, 138 patients could be classified as definite/probable DRESS and/or atypical DiHS. Japanese criteria did not diagnose atypical DiHS in 88/137 (64.2%) patients with definite/probable DRESS. RegiSCAR scoring system made a diagnosis of definite/probable DRESS in 49/50 (98%) patients with atypical DiHS. A total of 58/138 (42%) patients had a severe reaction. RegiSCAR scoring system diagnosed 57/58 (98.3%) patients with severe reaction as definite/probable DRESS. A total of 32/58 (55.2%) patients with severe reactions were diagnosed as atypical DiHS. The difference was statistically significant (<0.001). CONCLUSION: Japanese criteria for atypical DiHS showed reduced sensitivity to diagnose definite/probable DRESS, and this included more than 40% of patients with severe DRESS.

A Cross-Sectional Study of Nailfold Capillary Changes in Psoriasis.

BACKGROUND: Microcirculation in the skin of psoriasis patients significantly differs from unaffected individuals. Vascular changes precede skin lesions and occur even in nonlesional skin. AIMS: The primary aim of this work was to study the nailfold capillary changes in psoriasis patients, and to compare it with that of controls. The secondary aim of this work was to compare the nailfold capillary changes in psoriasis patients with and without nail changes. METHODS: A comparative cross-sectional study of 40 psoriasis patients and 40 age and sex-matched controls analyzed the capillaries of the proximal nailfold of all fingers using a dermoscope. The mean capillary loop density/mm, tortuous capillaries, capillary hemorrhages, and avascular areas were assessed. RESULTS: The mean nailfold capillary loop density in psoriasis (6.98 ± 0.54 per mm) was significantly less than that in controls (8.01 ± 0.61 per mm) (P < 0.001). Avascular areas in the nailfold of psoriasis patients (55%) were significantly more than the same in controls (22.5%) (P = 0.003). Of 40 psoriasis patients, 26 had nail psoriasis. Of this, 19 (73%) had avascular areas (P = 0.002). No significant association of nailfold capillary density or avascular areas with disease duration or severity was noted. An increase in tortuous capillaries and nailfold hemorrhages noted in psoriasis was not significant. LIMITATIONS: Small sample size, not having participants with psoriatic arthropathy, and lack of information on capillary diameter and capillary changes in hyponychium were the limitations. CONCLUSION: The reduced mean capillary loop density, and higher frequency of avascular areas noted in cases compared to controls, points to a pathogenic role for microvascular damage in psoriasis. Whether the lack of association of these changes with disease duration and severity suggests the possibility of these being early disease markers for psoriasis, needs further analysis in larger prospective studies.

Autoimmune Diseases, End Organ Dysfunction and Adverse Drug Reaction Following Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): A Retrospective Cohort Study.

CONTEXT: Autoimmune diseases, organ dysfunction and new drug allergies are mentioned as long-term complications after DRESS. There is scarcity of data on this from the country. AIMS: To determine the frequency of autoimmune diseases, organ dysfunction, and new drug allergies after the resolution of DRESS. SETTINGS AND DESIGN: This retrospective cohort study was carried out among patients who received treatment for DRESS in a tertiary referral center. MATERIALS AND METHODS: In this retrospective cohort study, DRESS patients who received inpatient care in the dermatology department of our tertiary referral center from August 2014 to February 2017 were included. We excluded patients aged 12 years or below and those who had not completed minimum two years after the resolution of DRESS as on December 2019. We collected information on new onset autoimmune disease, end organ damage and new drug allergies detected after the resolution of DRESS through a telephonic interview. Those who consented were evaluated in our department. RESULTS: We could contact 40/50 (80%) identified individuals and all of them consented for telephonic interview. 17 patients gave consent for revaluation in our department. There were 22 females and 18 males. 17 had definite and 23 had probable DRESS. The frequency of detection of a new disease and a new drug allergy after DRESS was 10% (4/40) and 7.5% (3/40), respectively. We noted three (7.5%) autoimmune diseases (rheumatoid arthritis 1, alopecia areata 1, chronic autoimmune urticaria 1) and one end organ damage (chronic kidney disease) among the study participants. LIMITATIONS: Small sample size and retrospective study design were the limitations. CONCLUSIONS: Prospective studies with large sample size are needed to delineate the link between DRESS and autoimmunity, end organ damage, and new drug allergies.

High-resolution ultrasound in the assessment of peripheral nerves in leprosy: A comparative cross-sectional study.

BACKGROUND: Detection of peripheral nerve thickening and nerve function impairment is crucial in the diagnosis and the management of leprosy. AIMS AND OBJECTIVES: (1) To document the cross-sectional area, echotexture and blood flow of peripheral nerves in healthy controls and leprosy cases using high-resolution ultrasound, (2) to compare the sensitivities of clinical examination and high-resolution ultrasound in detecting peripheral nerve thickening in leprosy. METHODS: Peripheral nerves of 30 leprosy patients and 30 age- and sex-matched controls were evaluated clinically and by high-resolution ultrasound. When the cross-sectional area of a peripheral nerve on high-resolution ultrasound in a leprosy patient was more than the calculated upper bound of the 95% confidence interval for mean for that specific nerve in controls, that particular peripheral nerve was considered to be enlarged. RESULTS: Cross-sectional areas more than 7.1 mm2 for the radial nerve, 8.17 mm2 for ulnar, 10.17 mm2 for median, 9.50 mm2 for lateral popliteal and 11.21mm2 for the posterior tibial nerve were considered as nerve thickening on high-resolution ultrasound. High-resolution ultrasound detected 141/300 (47%) nerves enlarged in contrast to the 60 (20%) diagnosed clinically by palpation (P < 0.001). Clinical examination identified thickening in 31/70 (44.3%) nerves in cases with impairment of nerve function and 29/230 (12.6%) in the absence of nerve function impairment. High-resolution ultrasound detected thickening in 50/70 (71.4%) nerves with impairment of function and in 91/230 (39.6%) nerves without any impairment of function. LIMITATION: A single-centre study design was the major study limitation. CONCLUSION: High-resolution ultrasound showed greater sensitivity than clinical examination in detecting peripheral nerve thickening in leprosy cases. High-resolution ultrasound, may therefore improve the sensitivity of the diagnostic criterion of peripheral nerve enlargement in the diagnosis and classification of leprosy.

Nail Changes in Leprosy: Onychoscopy Evaluation.

CONTEXT: Repeated trauma involving extremities (in the setting of peripheral neuropathy) and poor vascularity that impairs wound healing are important causes of disability and deformity in leprosy patients. Nail changes can serve as indicators of trophic changes due to leprosy. AIMS: To describe the onychoscopy findings in leprosy cases and to identify any specific findings in leprosy patients in comparison to controls. SETTINGS AND DESIGN: The first 30 leprosy patients and 30 age and sex-matched controls who attended our tertiary care center from 1 August 2018 were included in this cross-sectional study. MATERIALS AND METHODS: Onychoscopy examination of all fingernails was performed at 50× magnification using dinolite dermoscope AM4113ZT under non-polarizing light to document surface changes and under polarizing light to document pigmentation and vascular changes. STATISTICAL ANALYSIS: The observed nail changes in cases and controls were compared using Pearson's Chi-square test. RESULTS: Statistically significant association with leprosy was found for pitting, onycholysis, melanonychia, transverse lines, nail pallor, and onychauxis. Nail pallor was unique to leprosy patients. LIMITATIONS: Small sample size and not evaluating toenails were the major limitations of the study. CONCLUSIONS: Studies with large sample size are needed to assess the significance of nail pallor as a specific onychoscopy finding in leprosy.

Role of Histopathology in Predicting type 1 Lepra Reaction in Borderline Tuberculoid Leprosy.

CONTEXT: Lepra reactions if not managed promptly are an important cause of sudden onset nerve palsy and disability due to leprosy. AIM: To evaluate the usefulness of histology in predicting type 1 lepra reaction. SETTING AND DESIGN: After obtaining clearance from institutional research and ethics committees, all histologically proven borderline tuberculoid patients diagnosed at our center from 1.8.2016 to 31.7.2018 were included in this retrospective cross-sectional study. METHOD: Clinical details were collected from patient records. The pathologist who was blinded to clinical evidence of type 1 lepra reaction at the time of biopsy re-evaluated the histopathology slides for evidence of type 1 reaction. The data of individual patient was analyzed to identify those who had a type 1 reaction at the time of the biopsy or who developed a lepra reaction during follow up. STATISTICAL ANALYSIS USED: Association between histological evidence of type 1 reaction and clinical manifestation of the same subsequently, was assessed using Pearson's Chi square test. RESULTS: Study group comprised of 22 females and 18 males. Clinicohistological concordance was noted in 27 patients (67.5%). Subclinical type 1 reaction was documented in 11 patients (27.5%) based on histopathology evaluation. Five (45.5%) of these 11 patients subsequently developed clinical features of type 1 reaction. This was found to be statistically significant (P value 0.02). LIMITATIONS: Main limitation was the small sample size. CONCLUSIONS: Histology could serve as a useful tool in predicting future type 1 lepra reaction.

Interface dermatitis as an indicator of hepatic involvement in drug reaction with eosinophilia and systemic symptoms (DRESS).

BACKGROUND: There are conflicting reports on the association between interface dermatitis and hepatic involvement in DRESS. METHODS: A cross-sectional analysis of the clinical and the histopathologic features of DRESS was performed to study the association between the histopathology of the skin rash and hepatic involvement. RESULTS: The clinical and the histopathologic findings were evaluated in 40 cases of DRESS. Thirty patients (75%) had a hepatic involvement. Thirty (75%) biopsy specimens showed a combination of different inflammatory patterns. The interface dermatitis was noted in 24 specimens (60%). Twenty-one patients with the interface dermatitis had a hepatic involvement (P = .04). CONCLUSIONS: The skin rash of DRESS often shows the coexistence of different inflammatory patterns. The interface dermatitis showed a statistically significant association with the hepatic involvement in DRESS.

Histological Evaluation of Acquired Dermal Macular Hyperpigmentation.

CONTEXT: An umbrella term, acquired dermal macular hyperpigmentation (ADMH), has been proposed to denote conditions including ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus, and idiopathic macular eruptive pigmentation. AIMS: To classify the patients manifesting ADMH on the basis of histology. SETTINGS AND DESIGN: In this retrospective, cross-sectional study, histology specimens of patients of ADMH, who underwent skin biopsy in our institution from 1.1 2015 to 31.12.2017, were included after obtaining ethical clearance. MATERIALS AND METHODS: The histology specimens of patients of ADMH were reviewed by the pathologist and classified. Clinical features of individual patient were collected from previous records and the data analyzed. STATISTICAL ANALYSIS USED: Pearson's Chi-square test was used to determine significance of association between age of onset and duration of pigmentation with histology type. RESULTS: Three patterns of histology were identified in the study group (17 males and 13 females). Type 1: Basal cell degeneration and moderate to dense inflammation (12 patients, 40%), type 2: Significant pigment incontinence and sparse inflammation without basal cell degeneration, (12 patients, 40%), and type 3: sparse inflammation without basal cell degeneration or significant pigment incontinence (six patients, 20%). Statistically significant association was noted between age of onset of pigmentation and histology type (P value, 0.02). LIMITATIONS: Main limitation was the small sample size. CONCLUSIONS: Prospective studies evaluating the clinical progression and dermoscopy features and analyzing serial biopsies of ADMH patients may confirm whether the histology patterns observed represent different stages of same disease process or are different entities.

Clinico-epidemiological Study of Disability Due to Leprosy at the Time of Diagnosis among Patients Attending a Tertiary Care Institution.

BACKGROUND: With the declared elimination of leprosy as a public health problem, the World Health Organization has shifted the focus on the disabilities and deformities associated with leprosy. AIMS: The aim was to study the Grade 1 and Grade 2 disability among newly diagnosed leprosy patients. MATERIALS AND METHODS: All newly diagnosed leprosy patients attending the Outpatient Department of Government Medical College, Kozhikode, from January 1, 2013 to December 31, 2013 were included in the study and the Grade 1 and Grade 2 disabilities observed were analyzed. RESULTS: During the 1-year period, 76 patients were diagnosed to have leprosy. Grade 1 and Grade 2 disabilities were noted in 31.6% and 17.1%, respectively. Major factors identified as risk for leprosy disability at the time of diagnosis were age >45 years, >5 skin lesions, ≥2 thickened peripheral nerve trunks, pure neuritic and borderline tuberculoid spectra of leprosy. LIMITATION: As the study was conducted in a tertiary care center, it does not perfectly indicate the status in the community. CONCLUSION: Disability noted in nearly 50% of leprosy cases at the time of diagnosis highlights the need to improve the effectivity of existing health-care system in early case detection and timely referral. In addition, it underscores the need to educate the affected regarding protective eye, foot, and hand care, so that progression to Grade 2 disability can be prevented.

A 10-year Retrospective Descriptive Study on Pure Neuritic Leprosy from a Tertiary Referral Centre.

CONTEXT: Pure neuritic leprosy is a risk factor for grade 2 disability owing to the early nerve damage. AIMS: To study the clinical patterns of neuritic leprosy, to determine the percentage of patients manifesting grade 2 disability at the time of diagnosis and to identify any risk factors for the same. SETTINGS AND DESIGN: Retrospective descriptive study from previous case records of pure neuritic leprosy patients who attended a tertiary centre from 1st July 2007 to 30th June 2017. SUBJECTS AND METHODS: Data on patients who satisfied the World Health Organization (WHO) cardinal criteria for diagnosis of leprosy, who had no skin lesion of leprosy and had acid-fast bacilli negative status on skin smears were collected using a pre-set proforma. STATISTICAL ANALYSIS USED: The Chi-square test was used to assess statistical significance and logistic regression model was applied to avoid the effects of confounding factors. RESULTS: A diagnostic delay of >1 year was observed in 44% patients. At the time of diagnosis, grade 2 disability was documented in 60 (80%) of patients. No statistically significant risk factor was identified for grade 2 disability. LIMITATIONS: Retrospective nature and the study conducted in a tertiary care centre not reflecting the status in the community were the limitations. CONCLUSIONS: Grade 2 disability noted in 80% of patients points to the inherent nature of disease to cause early nerve damage. Diagnostic delay of >1 year documented in 44% of patients underscores the diagnostic challenges in the absence of skin lesions.