Dermoscopy of oral and genital mucosal lesions: A descriptive cross-sectional study protocol.

INTRODUCTION: Dermoscopy is a safe, rapid, and non-invasive tool that aids in the clinical examination of pigmented and non-pigmented lesions. The upward trend in the use of dermoscopy can be attributed to the availability of compact hand-held and sophisticated dermoscopes, that are small enough to be carried around in a pocket. The extent of dermoscopy is not only limited to the evaluation of cutaneous lesions but also involves its use in the assessment of mucosal lesions along with lesions of hair and nails. METHODS: In a descriptive cross-sectional study, subjects (n = 100) with oral or genital mucosal lesions will be enrolled. Following a thorough clinical examination, a dermoscopy of the lesion will be performed with Dermlite DL4© Dermoscope, having a magnification of 10x. Images obtained would be stored and evaluated for observing specific morphologic patterns on dermoscopy which would be utilized to describe those patterns and arrive at a specific diagnosis. Descriptive statistics will include mean and standard deviation to summarise quantitative variation. Dermoscopic features of oral and genital mucosal lesions will be estimated in percentage. PURPOSE OF STUDY: Mucosal lesions several times mimic each other morphologically. Performing a biopsy is not always feasible for oral and genital lesions because they may be difficult to reach and tend to bleed more profusely compared to the skin surface due to its rich vascular nature. Dermoscopy is a non-invasive tool that helps in the diagnosis that is used mostly for the evaluation of non-mucosal lesions. For the same reason, there is no or minimal information in the published literature with regard to dermoscopic patterns of mucosal lesions. The current study intends to describe dermoscopic patterns in oral and genital mucosal diseases so that this important information would assist the diagnosis in a non-invasive manner thereby reducing the need for invasive investigations like mucosal biopsy. EXPECTED CLINICAL OUTCOMES: To summarize, this research is intended to add to the scarce literature on dermoscopic findings of oral and genital mucosal lesions. The study findings would establish the diagnosis and eliminate the need for unwarranted invasive biopsies of mucosal lesions and, if need be, help in the selection of the biopsy site.

Oral Tofacitinib Therapy for the Effective Management of Netherton Syndrome.

An uncommon form of ichthyosiform erythroderma, Netherton Syndrome (NS) is inherited by an autosomal recessive pattern. Owing to eczematous skin lesions and the clinical features of atopy, NS is often initially diagnosed as atopic dermatitis. There are very few reports on NS in India. Hardly any case report or series that presents the use of biologicals for the treatment of NS reports the use of tofacitinib therapy. Therefore, it is essential to document such cases to promote further research to understand the underlying pathophysiology and find more effective treatments for the disease. A three-year-old boy, the second issue of a non-consanguineous marriage reported a history of waxing and waning of generalized reddish-brown scaly plaques all over the body and recurrent infections since birth. Multiple annular erythematous, partially blanchable papules to plaques with double-edge scaling were observed most prominently on the trunk. There was a diagnostic dilemma among erythrokeratoderma variabilis (EKV), atopic dermatitis (AD), and ichthyosis linearis circumflexa (ILC). The patient was administered betamethasone orally. However, there was no satisfactory relief or remission; therefore, oral tofacitinib therapy was initiated. The patient showed a good therapeutic response to oral tofacitinib at the dose of 0.3 mg/kg/day at the eighth-week follow-up.

Dermoscopic Findings in Clinically Diagnosed Cases of Plantar Warts, Corns, and Calluses: A Cross-Sectional Study.

INTRODUCTION:  With the naked eye, it can frequently be challenging to tell a plantar wart from a corn or callus. A non-invasive diagnostic method called dermoscopy allows for the inspection of morphological features that are not apparent to the unaided eye. This study aimed to examine the dermoscopic findings in pared and unpared cases of palmoplantar warts, corns, and calluses. METHODS: Seventy patients who had palmoplantar warts, corns, and calluses were included in this study. A predesigned structured format was used to document the dermoscopic findings. RESULT: The majority of patients (51.4%) had warts followed by callus (28.6%) and corn (20%). On dermoscopic examination, all unpared and pared cases of warts had homogenous black/red dots. Translucent central core was present in 92.85% unpared and 100% pared lesions of corns. Homogenous opacity was present in 75% unpared and 100% pared cases of callus. There was no association between unpared and pared lesions (p>0.05). CONCLUSION: The accuracy of identifying various clinical types of cutaneous warts, calluses, and corns can be improved by dermoscopy without paring.

Histopathology of Hair Follicle Epithelium in Patients of Recurrent and Recalcitrant Dermatophytosis: A Diagnostic Cross-Sectional Study.

CONTEXT: Recurrent and recalcitrant dermatophytosis is a major evolving health problem in India. Histopathology is important in the diagnosis of recurrent and resistant cases, as it is postulated that hair follicle epithelium is affected, acting as the reservoir leading to recurrence and recalcitrance. AIMS: This study aims to study histopathology of hair follicle epithelium in patients of recurrent and recalcitrant dermatophytosis. SETTINGS AND DESIGN: A diagnostic cross-sectional study was performed at tertiary care hospital and referral center in central India. MATERIALS AND METHODS: A 3 mm-sized punch skin biopsy was taken from 108 patients of recurrent or recalcitrant dermatophytosis involving hair follicles. Sections were stained by hematoxylin and eosin (H and E) stain in these patients followed by special stains such as periodic acid-Schiff (PAS) stain and Gomori methenamine silver (GMS) stain in 78 individuals where hair follicle was seen on H and E stain. RESULTS: In H and E stain, surface epidermis fungus was observed in 57/108 patients (52.7%). In hair follicle-positive sections (78), surface fungus was seen in 52.6% with H and E stain, 84.6% with PAS stain, and 91% with GMS stain. H and E was 62.12% sensitive and 100% specific to diagnose fungus when compared with PAS stain and 57.7% sensitive and 100% specific when compared with GMS stain. PAS was 91.5% sensitive and 85.7% specific when compared with GMS stain. Ectothrix infection was the most common form of hair infection observed in 87.2% cases with GMS stain. Simultaneous presence of fungus in hair follicle and stratum corneum was observed in 87.3% of patients. CONCLUSION: Majority of patients showed affection of hair follicles by dermatophytes in clinically chronic, recurrent, and recalcitrant dermatophytic infections. GMS stain is the acceptable gold standard for detection of fungal elements.

Causality or Relatedness Assessment in Adverse Drug Reaction and Its Relevance in Dermatology.

Causality assessment essentially means finding a causal association or relationship between a drug and drug reaction. Identifying the culprit drug or drugs can be lifesaving or helpful in preventing the further damage caused by the drug to our body systems. In dermatology practice, when it comes to cutaneous adverse drug reaction, this is much more important and relevant because many aetiologies can produce a similar cutaneous manifestation. There are multiple criteria or algorithms available as of now for establishing a causal relationship in cases of adverse drug reaction (ADR), indicating that none of them is specific or complete. Most of these causality assessment tools (CATs) use four cardinal principles of diagnosis of ADR such as temporal relationship of drug with the drug reaction, biological plausibility of the drug causing a reaction, dechallenge, and rechallenge. The present study reviews some of the established or commonly used CATs and its implications or relevance to dermatology in clinical practice.

Secukinumab efficacy and safety in indian patients with moderate-to-severe plaque psoriasis: Sub-analysis from FIXTURE, a randomized, placebo-controlled, phase 3 study.

TITLE: Secukinumab efficacy and safety in Indian patients with moderate-to-severe plaque psoriasis: sub-analysis from FIXTURE (Full Year Investigative Examination of Secukinumab vs. Etanercept Using Two Dosing Regimens to Determine Efficacy in Psoriasis), a randomized, placebo-controlled, phase 3 study. BACKGROUND: Evidence has suggested Interleukin (IL)-17A to be an important effector cytokine in the pathogenesis of psoriasis. Here, we report results for an Indian sub-population from a multinational study FIXTURE, designed to assess the safety, tolerability, and long-term efficacy of fully human anti-IL-17A monoclonal antibody secukinumab in patients with moderate-to-severe plaque psoriasis. MATERIALS AND METHODS: In this double-dummy, placebo controlled, 52-weeks phase 3 study FIXTURE, 149 Indian patients were randomized 1:1:1:1 to receive secukinumab at a dose of 300 mg or 150 mg, etanercept, or placebo. The study objective was to show the superiority of secukinumab over placebo at week 12, vis-à-vis proportion of patients achieving a reduction of 75% or more from the baseline in the psoriasis area-and-severity index score (PASI 75) and a score of 0 (clear) or 1 (almost clear) on a 5-point modified investigator's global assessment (IGA mod 2011) (co-primary end points). RESULTS: At week 12, 61.0% and 55.9% patients in secukinumab 300 mg and 150 mg groups, respectively, achieved PASI 75 response compared to 20.0% in the etanercept and 7.1% in the placebo groups. Similarly, IGA mod 2011 0 or 1 response was achieved by 43.9% and 20.6% in patients in the secukinumab 300 mg and 150 mg group, respectively, vs. 13.3% in the etanercept and 2.4% in the placebo groups at week 12. Likewise, higher proportions of patients in secukinumab 300 mg (41.5%) and 150 mg (20.6%) group were PASI 90 responders at week 12 than those in the etanercept (10.0%) or placebo (0.0%) groups. The incidences of adverse events (AEs), during the induction period were similar in all the treatment groups. Overall secukinumab was well-tolerated at both doses in the Indian sub-population. CONCLUSION: The results from the Indian sub-population suggest that secukinumab is an efficacious and safe drug for use in moderate-to-severe chronic plaque psoriasis.

Guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis: An Indian perspective.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous adverse drug reactions with a high morbidity and mortality that require immediate medical care. The various immunomodulatory treatments include systemic corticosteroids, cyclosporine, intravenous immunoglobulin, cyclophosphamide, plasmapheresis and tumor necrosis factor-α inhibitors. AIM: The ideal therapy of Stevens-Johnson syndrome/toxic epidermal necrolysis still remains a matter of debate as there are only a limited number of studies of good quality comparing the usefulness of different specific treatments. The aim of this article is to comprehensively review the published medical literature and frame management guidelines suitable in the Indian perspective. METHODS: The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) assigned the task of preparing these guidelines to its special interest group on cutaneous adverse drug reactions. The group performed a comprehensive English language literature search for management options in Stevens-Johnson syndrome/toxic epidermal necrolysis across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for keywords (alone and in combination) and MeSH items such as "guidelines," "Stevens-Johnson syndrome," "toxic epidermal necrolysis," "corticosteroids," "intravenous immunoglobulin," "cyclosporine" and "management." The available evidence was evaluated using the strength of recommendation taxonomy and graded using a three-point scale. A draft of clinical recommendations was developed on the best available evidence which was also scrutinized and critically evaluated by the IADVL Academy of Dermatology. Based on the inputs received, this final consensus statement was prepared. RESULTS: A total of 104 articles (meta-analyses, prospective and retrospective studies, reviews [including chapters in books], previous guidelines [including Indian guidelines of 2006] and case series) were critically evaluated and the evidence thus gathered was used in the preparation of these guidelines. RECOMMENDATIONS: This expert group recommends prompt withdrawal of the culprit drug, meticulous supportive care, and judicious and early (preferably within 72 h) initiation of moderate to high doses of oral or parenteral corticosteroids (prednisolone 1-2 mg/kg/day or equivalent), tapered rapidly within 7-10 days. Cyclosporine (3-5 mg/kg/day) for 10-14 days may also be used either alone, or in combination with corticosteroids. Owing to the systemic nature of the disease, a multidisciplinary approach in the management of these patients is helpful.

Correlation of serum antithyroid microsomal antibody and autologous serum skin test in patients with chronic idiopathic urticaria.

BACKGROUND: About 25-45% of patients of chronic urticaria (CU) have been stated to have histamine releasing autoantibodies in their blood. The term autoimmune urticaria is increasingly being accepted for this subgroup of patients. Review of the literature suggests high autologous serum skin test (ASST) positivity and presence of antithyroid microsomal antibodies in patients with autoimmune urticaria. AIMS: To study prevalence of ASST positivity and antithyroid microsomal antibodies in chronic "idiopathic" urticaria and to study the correlation between the two parameters. METHODS: All patients of chronic idiopathic urticaria satisfying inclusion/exclusion criteria were enrolled in the study after written informed consent. Patients of CU secondary to infections and infestations, physical urticaria including dermatographism, mastocytosis, urticarial vasculitis and those on treatment with immunosuppressive drugs for urticaria were excluded from the study. In all of these patients, complete blood count; ASST, serum T3/T4/thyroid stimulating hormone levels, antithyroid microsomal antibody (AMA) levels were done. Statistical analysis was done by Chi-square test, Fisher exact test and Kappa statistics. RESULTS: Study included 24 males and 26 females with mean age of 39.54 years. Majority of patients belonged to 20-40 years of age. Females showed more ASST positivity. A total of 12 out of 50 (24%) patients showed positive ASST. A total of four out of 12 (33.33%) had positive ASST and raised AMA levels. CONCLUSION: Only 25% of patients of chronic idiopathic urticaria had positive ASST. ASST and AMA levels were positively correlated in our study. Further studies are required to authenticate this association.

Clinical profile of cutaneous manifestations with and without hematologic disease: A comparative study.

AIM: The aim was to study the clinical profile of cutaneous manifestations of hematologic disorders and to compare it with that of non-hematologic disorders. MATERIALS AND METHODS: Cutaneous manifestations of hematologic diseases fall in seven well-defined categories. A total of 153 outpatients with skin manifestations fitting in these categories were enrolled in a comparative study of 1-year duration. Clinical profile of these cutaneous manifestations was studied and any underlying hematologic disorder was ruled out with the help of a hematologist. Difference in the clinical profile of cutaneous manifestations with and without hematologic diseases was studied. RESULT: Of the 26,174 outpatients during the study period, 153 had cutaneous manifestations fitting in the categories of hematologic disorders. Of these 153 patients, 33 had hematologic disease as the cause of their cutaneous manifestation (21.57%), whereas 78.42% had no hematologic disorder. Disorders of hemostasis formed the largest group (36%) followed by cutaneous deposits/infiltrations (15%), vesiculobullous disorders (6%), and cutaneous vasculitis (9%) were least commonly associated with hematologic disorders. CONCLUSION: Hematologic diseases are associated with complex array of cutaneous manifestations. The incidence of hematologic disease-associated cutaneous manifestations was 0.13%. Findings of this study will help dermatologists and physicians with the early recognition of cutaneous signs of hematologic disorders.

Cutaneous mercury granuloma.

Cutaneous mercury granuloma is rarely encountered. Clinically it may pose difficulty in diagnosis. Here, we report a 23-year-old male presented with erythematous, nodular lesions over the forearm and anterior aspect of chest wall. Metallic mercury in tissue sections appear as dark black, opaque, spherical globules of varying size and number. They are surrounded by granulomatous foreign-body reaction. It is composed of foreign body giant cells and mixed inflammatory infiltrate composed of histiocytes, lymphocytes, plasma cells, and few eosinophils.

Hormonal profile in Indian men with premature androgenetic alopecia.

INTRODUCTION: Alopecia in male is considered as a genetically determined disorder characterized by increased level of local androgen metabolite and increase androgen receptor binding in balding areas. Frequent deviations of hormones from normal values have been reported in men diagnosed with premature androgenetic alopecia (AGA) especially for androgens, gonadotropins and sex hormone binding globulin (SHBG). Different studies in the past have inferred that premature baldness before the age of thirty in males could be considered equivalent to the polycystic ovary syndrome (PCOS) in female. MATERIALS AND METHODS: Hormonal profile of 50 men with severe premature balding before 30 years of age were compared with same numbers of age matched controls. The serum concentrations of total testosterone, dehydroepiandrosterone sulfate, luteinizing hormone, follicle stimulating hormone, SHBG, insulin and fasting blood sugar were estimated. Statistical analysis was performed with paired Student's t-test for cases and controls. RESULTS: Decreased levels of SHBG with high free androgen index were found in cases when compared with the controls. CONCLUSION: Though altered hormonal profile may coexist in some of men with premature AGA it can't be considered as male equivalent to PCOS in female or the metabolic syndrome.

Phenomena in dermatology.

For a better understanding of various dermatoses, it is imperative for any physician practising dermatology to have a good theoretical knowledge of the underlying pathophysiologic processes involved in various systemic diseases involving the skin. For an easy grasp over this topic, we have discussed the various phenomena under three broad categories, like (a) clinical--Meyerson, Meirowsky, pathergy, Renbok, (b) laboratory--LE cell, prozone and (c) histopathology--Splendore-Hoeppli.

An open, nonrandomized, comparative study of imiquimod 5% cream versus 10% potassium hydroxide solution in the treatment of molluscum contagiosum.

BACKGROUND: There are numerous therapeutic modalities available for treatment of molluscum contagiosum. However, the ablative modalities are painful and not suitable for children. AIM: We aimed to evaluate and compare the safety and efficacy of 2 of the painless modalities, viz., 5% imiquimod cream and 10% potassium hydroxide (KOH) solution, in the treatment of molluscum contagiosum. METHODS: Out of a total of 40 patients of molluscum contagiosum in the study, 18 patients in the imiquimod group and 19 patients in the KOH group completed the study. The given medication was applied by the patient or a parent to mollusca at night, 3 days per week. Imiquimod was continued till clinical cure; and 10% KOH, till lesions showed signs of inflammation. Assessments of response and side effects were performed at the end of week 4, week 8, and week 12. Significance was tested by Student's t test and Mann-Whitney test. RESULTS: The mean lesion count decreased from 22.39 to 10.75 with imiquimod and from 20.79 to 4.31 with KOH at the end of 12 weeks. We found complete clearance of lesions in 8 (44%) patients with imiquimod and in 8 (42.1%) patients with 10% KOH. Minor side effects were seen in 15 (78.9%) patients on KOH and 10 (55.5%) patients on imiquimod. CONCLUSIONS: The results of this study suggest that both 5% imiquimod cream and 10% KOH solution are equally effective in molluscum contagiosum though KOH has a faster onset of action. However, KOH solution is associated with a higher incidence of side effects.

Griscelli syndrome: a new phenotype with circumscribed pigment loss?

Griscelli syndrome is a rare genetic immunodeficiency disorder characterized by pigment dilution, recurrent cutaneous and pulmonary infections, neurological deterioration, hypogammaglobulinemia, and defective cell-mediated immunity. Mutations of three distinct genes have been described in Griscelli syndrome with different phenotypes. The disease is usually fatal by the first decade of life. We report a 20-year-old female with Griscelli syndrome with circumscribed pigment loss over thighs and abdomen in addition to diffuse pigment dilution. An accelerated phase, similar to that described in Chediak-Higashi syndrome, was also observed in our case in the form of neurological deterioration. Survival of the patient beyond the first decade of life in the absence of specific therapy was also a distinctive feature.