Female sexual dysfunction: A clinical case series.

Introduction: Female sexual dysfunction (FSD) is a much-neglected area of medicine possibly due to the stigma attached to sexual functioning in most religions and cultures. Materials and Methods: Here, we report a case series of 12 females with FSD from the data collated from the sexual dysfunction clinic of a tertiary care hospital in South India. Results: Of the 370 patients who were seen in the sexual dysfunction clinic, only 12 (3.24%) were women aged from 22 to 58 years with a duration of marriage 3 months to 25 years. The commonly encountered problems were dyspareunia and hypoactive sexual disorder. Three had nonconsummated marriages. After evaluation, two patients were treated with antipsychotics and all were offered psychosexual counseling. Conclusion: Female sexual dysfunction remains unrecognized and under reported, especially in patriarchal cultural societies of the Indian subcontinent.

Burden of Disease, Unmet Needs in the Diagnosis and Management of Atopic Dermatitis: An Indian Expert Consensus.

BACKGROUND: Atopic dermatitis (AD) is a chronic inflammatory, non-communicable, and relapsing skin disease that affects all age groups. There is a dearth of literature that reports the disease burden, and epidemiology and highlights unmet needs in the diagnosis and management of AD in India. METHODS: A total of ten specialists including dermatologists, pediatric dermatologists, and pediatricians with more than ten years of experience and practicing in different parts of India served as the expert panel during the virtual meet conducted on January 24, 2021. A questionnaire comprising 32 questions on different aspects of AD management was categorized among different sections: burden of disease (five questions), age of onset and prevalence (five questions), etiology and pathogenesis (six questions), diagnosis and severity of the disease (seven questions), and treatment (nine questions). Consensus was defined when agreement was provided by ≥90% of the experts. RESULTS: Considering the profound impact AD has on the quality of life (QoL) of patients, the expert panel recommended patient counseling while moderate to severe cases of AD need a prompt referral to a specialist. The panel did not recommend any specific diagnostic and severity criteria as a standard due to the inherent limitations associated with every criterion. The role of environment and changing lifestyle in addition to genetic and familial risk factors for AD was also considered. The panel unanimously recommended to conduct a countrywide, multicenter survey/study to estimate the true prevalence of AD in India. Further, the experts recommended to follow proper treatment protocols and to perform longitudinal monitoring for understanding corticosteroid treatment associated side effects. CONCLUSION: This guidance focuses on identifying the unmet gaps and provides practical recommendations for improving QoL, diagnosis, prognosis, and overall management of patients with AD in India.

Update on Pharmacotherapy in Psychodermatological Disorders.

Psychodermatological (PD) conditions encountered in dermatologic practice include primary psychiatric conditions such as delusions of parasitosis or secondary psychiatric conditions such as anxiety and depression due to dermatologic disease. The psychotropics include antipsychotic agents, anti-anxiety agents, antidepressants, and miscellaneous drugs such as anti convulsants. Anti psychotics are further divided into first-generation and second-generation drugs. Currently, second-generation drugs e.g., risperidone are preferred over first-generation drugs e.g., pimozide in delusional infestation owing to the side effect profile of the latter. Anti-anxiety agents include benzodiazepines used in acute anxiety and buspirone in chronic anxiety disorders. They are frequently prescribed along with antidepressants. Although dependence and necessity of tapering is a problem with benzodiazepines, delayed onset of action is a feature of buspirone. The commonly used antidepressants in dermatology include selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), selective serotonin norepinephrine reuptake inhibitors (venlafaxine, desvenlefaxine, and duloxetine), norepinephrine dopamine reuptake inhibitors (bupropion), tricyclic antidepressants (doxepin, amitriptyline, imipramine, and clomipramine), and tetracyclic antidepressants (mirtazapine). Miscellaneous drugs include anticonvulsants such as gabapentin and pregabalin, naltrexone, and N-acetyl cysteine. The principles of PD treatment are first establish the psychiatric diagnosis, followed by initiating drug treatment. The choice of drugs is dependent on multiple factors such as side-effect profile, drug interactions, and co-morbid conditions. Usually, drugs are started at a low dose and gradually increased. A literature search was done in Pubmed, Google Scholar, and Medline databases, and articles on treatment were analyzed.

Comparative Efficacy of 10% Sodium Hydroxide, 88% Phenol, and 90% Trichloroacetic Acid as Chemical Cauterants for Partial Matricectomy in the Management of Great Toe Nail Onychocryptosis.

CONTEXT: Lateral plate avulsion with chemical matricectomy is the treatment of choice for ingrown toenails. Phenol is the most widely used cauterant, followed by 10% NaOH and more recently trichloroacetic acid. AIMS: To evaluate the efficacy of 10% NaOH, 88% Phenol, and 90% TCA in cauterizing the matrix with regular follow up post surgery and clinical photographs. MATERIALS AND METHODS: Fifteen adult patients presenting with ingrowing toe nails were recruited to the study with prior consent. The NaOH group (Group A) had five patients and five nails treated, the phenol group (Group B) had five patients and six nails treated, and the TCA group (Group C) had five patients and six nails treated. A total of 17 great toe nails were treated. Following proximal digital block and partial nail avulsion, the matrix was curetted and the lateral horn cauterized with 10% NaOH (1 min), 88% phenol (3 min), and 90% TCA (3 min). Post-procedure follow-up was done at weekly intervals to evaluate post-operative pain, oozing, and wound healing. STATISTICAL ANALYSIS USED: Graph pad prism software was used for statistical analysis. ANOVA tests were used to test the statistical significance between post-operative parameters of each group. RESULTS: Mean duration of post-op pain in Group A was 4.2 days; Group B was 8.6 days, and Group C was 1.2 days. Oozing occurred for a mean duration of 10.6 days in Group A, 14 days in Group B, and 5.6 days in Group C. Mean duration of tissue re-epithelization was 28.4 days in Group A, 40.5 days in Group B, and 27.4 days in Group C. CONCLUSIONS: TCA is an effective cauterant for chemical matricectomy with the advantage of less duration of post-op pain and faster healing.

The chik sign in dengue.

The "chik sign" is considered to be one of the most common cutaneous features of chikungunya fever and has been considered unique to this disorder. It consists of brownish hyperpigmentation involving the nose. We report a case of a 3-year-old boy with dengue infection who presented with macular hyperpigmentation of nose simulating the chik sign. Hyperpigmentation is an unusual cutaneous manifestation in cases of dengue.

Granuloma multiforme: an uncommon differential for leprosy.

Granuloma multiforme (GM) is a chronic granulomatous skin condition which is clinically characterised by annular lesions mainly over sun-exposed areas and histologically by focal necrobiosis and histiocytic granulomas. Its significance lies in the fact that it can clinically resemble tuberculoid leprosy and hence it can be missed. Here, we report a case of GM from India in a 55-year-old female agriculturist, with multiple asymptomatic large annular rings of papules over the photo-distributed areas. Histopathology helps in confirming the diagnosis and in differentiating it from similar clinical and histologic mimics such as granuloma annulare, tuberculoid leprosy, interstitial granulomatous dermatitis or annular sarcoid. Though a high degree of suspicion is needed to diagnose GM, it should be considered as a differential for various annular conditions.

Psychodermatology: An Indian perspective.

Psychodermatology, a relatively neglected branch of dermatology in India, refers to a holistic approach to skin diseases involving not only the mind and skin, but also the cutaneous effects of psychologic stress. Among many Indian people, culture, religion, the belief in karma, and the tendency to prefer indigenous medical systems can all have a major impact on lifestyle, as well as the approach to managing various diseases, including dermatologic conditions. The origin of psychodermatology in India can be traced to Buddha's period. Indigenous medical systems, such as Ayurveda, Yoga, and Unani, advocate control of skin disease through meditation, exercises, and related practices. Scientific practice of psychodermatology is still lacking in India, although there is an increasing understanding of the mind-skin connection among both health care providers and patients who have access to information over the Internet. The first dedicated psychodermatology liaison clinic was established in 2010 in Manipal, India. The common problems encountered have been anxiety, dysthymia, and depression, especially in patients with psoriasis, vitiligo, and urticaria.

Psychodermatology liaison clinic in India: a working model.

Literature reports suggest that up to 30% of dermatology patients have associated psychiatric co-morbidity. A psychodermatology liaison (PD) clinic is essential to deal with such patients, which is almost non-existent in the Indian scenario. In order to report the working pattern of such a clinic and to determine its efficacy with the help of Dermatology Life Quality Index (DLQI) and Short Assessment of Patient Satisfaction (SAPS) questionnaires, we investigated patients with suspected psychocutaneous diseases in an open-labelled two-year prospective study. Of 236 patients, 86 had psychiatric co-morbidity, 19 had primary psychiatric disorders, 144 were advised psychological interventions and 98 were prescribed psychotropics. A statistically significant fall in DLQI scores at follow-up indicated improvement in quality of life. SAPS scales demonstrated 87.3% of patients in our PD clinic were satisfied with their management in contrast to 53.8% patients in the normal standard dermatology clinic. Nearly 33% of the patients attending our PD clinic had psychiatric co-morbidity, the commonest being an adjustment disorder.

Detection of Anti-basement Membrane Zone Antibodies in the Blister Fluid in Subepidermal Autoimmune Bullous Diseases.

BACKGROUND: Subepidermal autoimmune bullous diseases (sAIBD) are diverse of conditions with clinicopathological overlap. Circulating autoantibodies in the serum can be demonstrated using indirect immunofluorescence (IIF) microscopy. Artificially split normal human skin is considered as an optimum substrate for the demonstration of anti-basement membrane zone (BMZ) antibodies using IIF in sAIBD; it not only helps to detect the presence of circulating antibodies in the serum but also helps to subclassify these conditions into "roof" and "floor" binding disorders. AIM: In this study, we evaluated the utility of IIF to detect anti-BMZ antibodies in the blister fluid of patients with sAIBD. MATERIALS AND METHODS: Twenty-two patients with a clinical diagnosis of sAIBD were enrolled in the study. IIF of serum and blister fluid were done simultaneously using salt-split skin as a substrate. RESULTS: Anti-BMZ antibodies could be detected in the blister fluid using IIF in all patients in the study group. LIMITATION: We could not do enzyme-linked immunosorbent assay of blister fluid. This would have given us the quantitative data of circulating antibodies in the blister fluid. CONCLUSION: Blister fluid offers an alternate source for the detection of autoantibodies in patients with sAIBD. It may be of particular help in children and in elderly with poor venous access.

Epidermolysis bullosa acquisita and anti-p200 pemphigoid as major subepidermal autoimmune bullous diseases diagnosed by floor binding on indirect immunofluorescence microscopy using human salt-split skin.

BACKGROUND: Subepidermal autoimmune bullous diseases are a diverse group of diseases with overlapping clinical and immunopathological features. Indirect immunofluorescence microscopy on artificially split skin helps to classify these conditions into those with staining on the epidermal side of the split ("roof-binding") and those with staining on the dermal side ("floor-binding"). Epidermolysis bullosa acquisita is the prototype of "floor-binding" subepidermal autoimmune bullous diseases. However, not all floor-binding sera are associated with epidermolysis bullosa acquisita. AIM: The aim of this study was to evaluate the clinical and immunological profile of patients with floor-binding subepidermal autoimmune bullous disease by indirect immunofluorescence microscopy and to identify the target antigens in them. METHODS: Ten patients who showed a floor-binding pattern were studied with regard to their clinical and immunopathological characteristics. Target antigens were identified by modified indirect immunofluorescence microscopy using recessive dystrophic epidermolysis bullosa skin, enzyme linked immunosorbent assay, and immunoblotting. RESULTS: Diagnosis of epidermolysis bullosa acquisita was confirmed in six patients. Three patients with an inflammatory subepidermal autoimmune bullous disease mimicking bullous pemphigoid reacted with a 200 kDa protein on immunoblotting with dermal extract, as is characteristic of anti-p200 pemphigoid. One serum showed both roof and floor binding, and reacted with the BP180 antigen. LIMITATION: We could not perform serration pattern analysis in our patients. CONCLUSION: In this study, we report three cases of anti-p200 pemphigoid from India. These cases, though indistinguishable clinically from bullous pemphigoid, revealed a floor-binding pattern on indirect immunofluorescence using salt-split skin.

Diagnosis and Management of Chronic Pruritus: An Expert Consensus Review.

The aim of this study is to formulate the best clinical practice in the diagnosis and management of chronic pruritus (CP). We searched PubMed, EMBASE, Scopus, Web of Science, and the WHO's regional databases, for studies on "Diagnosis and management of chronic pruritus" from January 1, 2014, to July 31, 2015. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data. We screened 87 of 95 studies that contained qualitative data. Avoid: Dry climate, heat, alcohol compress, ice packs, frequent bathing and washing, intake of very hot and spicy food, intake of alcohol, contact with irritant substances, excitement, strain and stress, and allergens. Using: Mild nonalkaline soaps, moisturizers, bathing oils, lukewarm water while bathing, soft cotton clothing and night creams/lotions, relaxation therapy, autogenic training, psychosocial education, educating patients to cope with itching and scratching, and educational programs. Especially use of moisturizers is considered important. In addition, symptomatic treatment options include systemic H1 antihistamines and topical corticosteroids. Symptomatic therapy directed toward the cause (hepatic, renal, atopic, polycythemia, etc.). If refractory or cause is unknown, consider capsaicin, calcineurin inhibitors for localized pruritus and naltrexone, pregabalin, ultraviolet therapy, Cyclosporine for generalized itching. CP is quite frequent finding associated with skin and systemic diseases in the overall population. It is known to significantly affect quality life score of an individual and also adds burden on the health-care cost. A specific recommendation for treatment of CP is difficult as a result of varied and diverse possibility of underlying diseases associated with CP.

Multiple trichofolliculomas mimicking multiple trichoepitheliomas.

Trichofolliculomas are benign hair follicle hamartomas which were initially considered as hair follicle tumors. Usually presenting as a solitary lesion associated with a tuft of vellus hairs, multiple trichofolliculomas are rare. Trichofolliculomas are characterized by a histopathological feature of dermal keratin cyst with cyst wall showing radiating hair follicles. We report this case for the rare presentation of multiple trichofolliculomas on the face which clinically mimicked multiple trichoepitheliomas.