Fractional Laser Resurfacing for Acne Scars: Our Experience at Tertiary Care Hospital of North India.

Background: Acne is very common among adolescents, which may sometimes persist into adulthood, and acne scars continue to have a profoundly negative impact on quality of life. Of all the various modalities available, fractional lasers have shown effective results. Aims and Objectives: The aim of this study was to assess the efficacy and safety of fractional carbon dioxide (CO2) laser resurfacing in atrophic facial acne scars. Materials and Methods: The study included 104 subjects aged ≥18 years with atrophic acne scars on face of more than 6 months of duration recruited over a period of 1 year. All the patients were treated with fractional CO2 laser (600 W power and wavelength 10,600 nm). Four sessions of fractional CO2 laser resurfacing were done at 6-week intervals in each patient. We compared the improvement rate of scars after every session at 6-week interval, 2 weeks after the last session, and finally 6 months after the last laser session. Results: The difference between the mean baseline score (3.43) and mean final score (1.83) using Goodman and Baron's qualitative scar scale was found to be statistically significant (P = 0.001). Mean improvement increased from first treatment session to the end of the treatment course from 0.56 to 1.62 indicating the role of the number of sessions in the overall improvement of acne scars. With regard to overall satisfaction, maximum number of patients were either very satisfied (55.8%) or satisfied (25%) as compared to those who were only slightly satisfied (11.5%) or completely unsatisfied (7.7%). Conclusion: Fractional ablative laser gives excellent results in the management of acne scars and has emerged as an appealing non-invasive option for this indication. Being a safe and effective option for atrophic acne scar treatment, it can be recommended wherever available.

Management of Pre-malignant and Malignant Non-melanoma Skin Cancers: A Study from a Tertiary Care Hospital of North India.

Introduction: The incidence of non-melanoma skin cancers (NMSCs) is increasing over the last few decades. This necessitates an early diagnosis which is nowadays aided by dermoscopy. Once diagnosed early, the treatment armamentarium is diverse and includes both topical and surgical modalities. Objective: Our aim was to diagnose pre-malignant and malignant NMSCs at an early stage and treat them as per the standard protocol. Materials and Materials: Out of 136 patients of pre-malignant and malignant tumors enrolled, 100 were taken up for treatment. These were then classified into various subtypes on the basis of clinical examination and dermoscopy. The selected patients were subjected to topical treatment or surgical modalities, wide local excision or flap excision, based on the type of tumor and its size. Results: The pre-malignant group included actinic keratoses, Bowen's disease, and keratoacanthoma, whereas the malignant group included undifferentiated squamous cell carcinoma (SCC), differentiated SCC, pigmented basal cell carcinoma (BCC), nodulo-ulcerative BCC, and superficial BCC. Actinic keratoses, superficial BCCs, and five cases of keratoacanthoma were treated with topical therapies with a resolution of 90% in 86.8% cases. All the remaining cases (62 in number) were treated with conventional and flap surgery with 88% and 89.1% clearance rates, respectively, with complications in only 7 patients. Conclusion: A prompt identification of NMSCs can enable selection of the appropriate treatment modality for a specific lesion and thus reduce their associated morbidity and mortality.

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.

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.

Clinicoepidemiological and Mycological Study of Tinea Capitis in the Pediatric Population of Kashmir Valley: A Study from a Tertiary Care Centre.

BACKGROUND: Tinea capitis is a superficial fungal infection that predominantly affects the pediatric population. The etiological factors vary from region to region, and the exact incidence remains obscure. The clinicoepidemiological and mycological aspects of this dermatophytosis were studied in a tertiary care centre in Kashmir valley. AIM: To determine the clinicoepidemiological aspects and mycological findings of dermatophytes involved in tinea capitis cases in Kashmir valley. MATERIALS AND METHODS: Wood's lamp examination, KOH examination, and fungal culture were performed in one hundred fifty clinically diagnosed cases of tinea capitis with patients' age upto 14 years over a period of 6 months. The epidemiological factors associated with the disease were also evaluated. RESULTS: Tinea capitis was predominant in the 3-6 and 6-9 years age groups with a male preponderance. Grey patch tinea capitis was the most common variant. KOH positivity was 76%, and Trichophyton tonsurans was the most common fungal isolate. CONCLUSION: Tinea capitis is a very common fungal infection in our setting. Early detection and diagnosis is mandatory to prevent its spread in the community as well as the development of scarring alopecia in the affected individual.

Evaluation of Carbon Dioxide Laser in the Treatment of Epidermal Nevi.

BACKGROUND: Epidermal naevi are benign hamartomatous growths of the skin which are generally asymptomatic with a benign course but are cosmetically disagreeable. Topical treatments such as steroids, calcipotriol, 5 fluorouracil, podophyllin, retinoids and cryotherapy are ineffective and surgical excision results in scar formation. Therapy is often challenging. AIM OF THE STUDY: To study the response of carbon dioxide (CO2) laser in the management of epidermal naevi. SUBJECTS AND METHODS: We conducted a study of CO2 laser treatment on 15 patients of epidermal naevi, eight with verrucous epidermal naevi and seven with sebaceous naevi. A thorough history and examination was done to rule out any epidermal naevus syndrome. The diagnosis was confirmed by histopathology. The number of treatment sessions varied from 1 to 8. RESULTS: Response was excellent (>90% reduction in lesion size) in three patients, very good (>75% reduction) in five, good (>50% reduction in lesion size) in five and poor (<50% reduction in lesion size) in two patients. The side effects were hyperpigmentation and scarring. Long-term follow-up over a period of 10 months showed a recurrence rate of 20%. CONCLUSION: We conclude that CO2 laser treatment might be an effective option with long-term safety, minimal discomfort and rapid recovery.

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.

Acute Generalized Exanthematous Pustulosis Due to Insect Bites?

Acute generalized exanthematous pustulosis is a rare severe cutaneous adverse reaction pattern that is mostly caused by the intake of drugs and rarely associated with viral infections, food allergens or toxins. Here we present the report of three patients who got admitted in our hospital for generalized pustulosis and fever after insect bites. The diagnosis of acute generalized exanthematous pustulosis was made by EuroSCAR scoring. The drug etiology was excluded and spider bite was implicated as the etiological agent in these cases of AGEP which are the first such reported cases in India.

Contact dermatitis in saffron workers: clinical profile and identification of contact sensitizers in a saffron-cultivating area of Kashmir Valley of North India.

BACKGROUND: Saffron, a bulbous perennial plant belonging to Iridaceae family, is the most expensive cultivated herb that is widely used for industrial and nonindustrial purposes. However, besides its attractive and valuable properties, contact dermatitis due to saffron is an uncommon reported entity. OBJECTIVES: The aims of this study were to determine the clinical pattern patch-testing profile of contact dermatitis in saffron workers and to identify the most common allergens/sensitizers. MATERIAL AND METHODS: One hundred ten saffron workers were patch-tested with 39 allergens, which included Indian standard series antigens, plant series antigens, and extracts from different parts of saffron flower. RESULTS: The allergens in Indian standard series accounted for 52.44% of positive reactions. Plant series and different parts of saffron accounted for 47.56% of the positive reactions. Among those patients with positive responses to the supplemental saffron allergens, 83.3% were of present or past relevance. CONCLUSIONS: The data observed in the present study confirm that the saffron dermatitis is a distinct clinical entity with characteristic clinical presentation and has a strong significance as an occupational allergen in those handling this plant. Patch testing with different parts of saffron flower has a role to play in finding out the etiological cause.

De novo histoid leprosy: a case report from a post-elimination area.

Histoid leprosy is an uncommon variant of lepromatous leprosy that usually follows treatment failure. Occasionally it occurs de novo without any history of previous inadequate or irregular treatment. We, hereby, report a case of de novo histoid leprosy in a 25-year-old man from the post-elimination area of Kashmir, where the prevalence rate of the disease was reported to be 0.17/10000 in March, 2013 (NLEP).