Assessment of cutaneous disease activity in early lupus and its correlation with quality of life: a cross-sectional study.

Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease with varied dermatological manifestations that are almost universal. Overall, lupus disease has a major effect on the quality of life in these patients. We assessed the extent of cutaneous disease in early lupus and correlated it with the SLE quality-of-life (SLEQoL) index and disease activity measures. Patients diagnosed as SLE with the skin involved were recruited at the first presentation and were assessed for cutaneous and systemic disease activity using the cutaneous lupus erythematosus disease area and severity index (CLASI) and the Mexican-SLE disease activity index (Mex-SLEDAI), respectively. Quality of life was assessed with the SLEQoL tool while systemic damage was captured by the SLICC damage index. Fifty-two patients with SLE who had cutaneous involvement were enrolled (40, 76.9% females) with a median disease duration of 1 month (1-3.7). The median age was 27.5 years (IQR: 20-41). Median Mex-SLEDAI and SLICC damage index were 8(IQR: 4.5-11) and 0 (0-1), respectively. The median CLASI activity and damage scores were 3 (1-5) and 1 (0-1), respectively. Overall, there was no correlation between SLEQoL with CLASI or CLASI damage. Only the self-image domain of SLEQoL correlated with total CLASI (ρ = 0.32; p = 0.01) and CLASI-D (ρ = 0.35; p = 0.02). There was a weak correlation of CLASI with the Mexican-SLEDAI score (ρ = 0.30; p = 0.03) but not with the SLICC damage index. In this cohort of early lupus, cutaneous disease activity in lupus had a weak correlation with systemic disease. Cutaneous features did not appear to influence the quality of life except in the self-image domain.

Plucked Hair as a Substrate for Indirect Immunofluorescence in Cases of Pemphigus Vulgaris.

INTRODUCTION: Indirect immunofluorescence (IIF) is used to determine the circulating autoantibodies in cases of Pemphigus. For IIF in Pemphigus several substrates had been used. This study was done to determine whether plucked hair can be utilized as a substrate for IIF in cases of Pemphigus. Aim & Objectives: To determine the efficacy of utilizing the plucked hair as a substrate for indirect immunofluorescence among patients with Pemphigus vulgaris. METHODOLOGY: Thirty two consecutive patients with active and fresh diagnosed cases of pemphigus vulgaris (PV) who did not undergo any treatment and those patients who had positive DIF findings of characteristic fish net or chicken wire pattern of intercellular IgG deposits in the epidermis of perilesional skin were included in the study. A total of 32 control subjects without any auto immune disorders were selected and the blood samples were taken from these patients for IIF analysis. Anagen hair were collected from the healthy volunteers without pemphigus in the same way as for trichogram. Telogen hair were obtained by combing the hair and collecting the loose strands of hair on the comb and further confirmed under microscope. Three hairs each of anagen and telogen stage were collected from each subject to be utilized as a substrate for IIF. RESULTS: Out of 32 samples 20 samples showed positive results for Ig G alone and 5 samples showed positivity for Ig G and C3. One sample showed positivity for C3alone. All these 26 samples were considered to have positive IIF test based on the intercellular pattern of deposit. Positive IIF results were observed in anagen hair samples and were negative in all the telogen hair samples. Six anagen hair samples did not show any positive findings in IIF for the study group. All the 32 control samples showed negative reports in IIF. CONCLUSION: In conclusion, IIF microscopy on plucked hair as a substrate is a more sensitive immunoassay for the detection of circulating intercellular autoantibodies in PV and the lower negative predictive value of this substrate is a limitation. Further large scale studies might provide better information regarding the practical utility.

Primary Chylous Lymphangiectasia of Female Genitalia.

We report a case of a 50-year-old female who presented with multiple thick-walled vesicles involving the labia majora and minora which started developing at the age of 10 year. The vesicles extruded milky white fluid when punctured. Biochemical analysis of the fluid was consistent with chyle. Lymphoscintigraphy showed reflux of the radioactive tracer into the genitalia, thus confirming the diagnosis of primary chylous lymphangiectasia. The patient was not willing to undergo definitive surgical treatment. We report the case considering the rarity and to depict the usage of biochemical analysis of the vesicular content and lymphoscintigraphy to detect this entity.

Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India).

BACKGROUND: Dermatophytosis management has become an important public health issue, with a large void in research in the area of disease pathophysiology and management. Current treatment recommendations appear to lose their relevance in the current clinical scenario. The objective of the current consensus was to provide an experience-driven approach regarding the diagnosis and management of tinea corporis, cruris and pedis. METHODS: Eleven experts in the field of clinical dermatology and mycology participated in the modified Delphi process consisting of two workshops and five rounds of questionnaires, elaborating definitions, diagnosis and management. Panel members were asked to mark "agree" or "disagree" beside each statement, and provide comments. More than 75% of concordance in response was set to reach the consensus. RESULT: KOH mount microscopy was recommended as a point of care testing. Fungal culture was recommended in chronic, recurrent, relapse, recalcitrant and multisite tinea cases. Topical monotherapy was recommended for naïve tinea cruris and corporis (localised) cases, while a combination of systemic and topical antifungals was recommended for naïve and recalcitrant tinea pedis, extensive lesions of corporis and recalcitrant cases of cruris and corporis. Because of the anti-inflammatory, antibacterial and broad spectrum activity, topical azoles should be preferred. Terbinafine and itraconazole should be the preferred systemic drugs. Minimum duration of treatment should be 2-4 weeks in naïve cases and > 4 weeks in recalcitrant cases. Topical corticosteroid use in the clinical practice of tinea management was strongly discouraged. CONCLUSION: This consensus guideline will help to standardise care, provide guidance on the management, and assist in clinical decision-making for healthcare professionals.

Kumkum-induced allergic contact dermatitis: Are we missing the actual culprit?

BACKGROUND: Kumkum, made with turmeric and slaked lime along with colour enhancing dyes is known to cause allergic contact dermatitis. The possible contact allergens in kumkum include turmeric, Sudan-1, 4-aminoazobenzene, brilliant lake red R and cananga oil. We report patch test results among patients with suspected contact hypersensitivity to kumkum. OBJECTIVE: To identify the allergen causing kumkum induced allergic contact dermatitis by patch testing and to advise patients about organic kumkum which doesnot contain colour enhancing dyes. METHODS: Eighteen patients with suspected contact hypersensitivity to kumkum were patch tested with undiluted kumkum, undiluted turmeric, Sudan-1 (95%), 4-aminoazobenzene and allergens of the Indian Standard Series. RESULTS: Of the 18 patients, 14 patients had patch test positivity to kumkum and 4 had a negative reaction to kumkum. Patch test with other suspected contact allergens showed positive reaction to turmeric in 4 patients, Sudan-1 in 3 patients and 4-aminoazobenzene in 2 patients. Among the allergens of the Indian Standard Series, positivity to nickel and fragrance mix was seen in 5 and 2 patients respectively. Positive reaction to PPD, chlorocresol and parthenium was seen in 1 patient each. LIMITATION: Small sample size. CONCLUSION: Allergic contact dermatitis to kumkum occurs both due to the dyes (added for enhancing the colour) and turmeric. All patients with suspected allergic contact dermatitis should be patch tested with kumkum, turmeric and dyes, based on which alternative non-allergic material could be advised. Kumkum dermatitis can also occur due to various other allergens, for which too patch testing should be done.

Fractional Carbon Dioxide, Long Pulse Nd:YAG and Pulsed Dye Laser in the Management of Keloids.

BACKGROUND: Keloids are abnormal wound responses characterised by excessive deposition of collagen and glycoprotein. They are both aesthetically and symptomatically distressing for most of the patients. There are reports of keloid management with pulsed dye laser (PDL), fractional carbon dioxide (CO2) laser and neodymium-doped yttrium aluminium garnet (Nd:YAG) laser individually and also in combination of CO2 with PDL and CO2 with Nd:YAG. Here, we discuss a combination of all the 3 lasers as a therapy for keloids. AIM: This study aims to assess the efficacy of fractional CO2 laser, long pulse Nd:YAG laser and PDL in the management of keloids. MATERIALS AND METHODS: Fifteen patients with keloids were treated by fractional CO2 laser, followed by PDL and long pulse Nd:YAG laser at monthly intervals. Four patients discontinued the study and were lost for follow-up. Photographs were taken at the beginning of the treatment and at the end of five sessions. Clinical improvement was analysed based on a visual analogue scale graded by three blinded observers after assessing the clinical photographs for the improvement in size, colour and aesthetic impression. RESULTS: Of the 11 patients, one patient had excellent improvement, one patient had good improvement, four patients had moderate improvement, two patients had mild improvement and three had no improvement. CONCLUSION: Lasers may have a synergistic effect when combined with other modalities of treatment but cannot be used as monotherapy in the treatment of keloids.

Counseling in Pemphigus.

Pemphigus is a chronic, potentially life threatening, autoimmune intraepidermal blistering disease affecting the skin and the mucous membrane. Pemphigus may have profound impact on the quality of life in the affected patients. Counselling and adjuvant psychotherapy may be beneficial at least in few patients and should be considered as a part of multidisciplinary approach.

Spring-loaded Syringe for Multiple Rapid Injections.

Mesotherapy refers to multiple injections of small quantity of the drug over a large area. The mesoguns available are expensive and the motor-driven models tends to waste the expensive material to be injected since the plunger stops after injecting without recoil. We searched for a less expensive device which would inject like the mesogun and still not waste the solution. On searching the web, we identified a spring-loaded syringe. We describe the assembly and use of this inexpensive syringe for delivering multiple injections with minimal wastage.

Effect of Oil Application, Age, Diet, and Pigmentation on the Tensile Strength and Breaking Point of Hair.

BACKGROUND: Hair strength depends on various factors such as nutrition, environmental factors, sunlight, oiling, aging, conditioner, etc. AIM: To compare the tensile strength and breaking point of the hair shaft between (1) vegetarian and nonvegetarian. (2) Those who regularly apply and those who do not apply oil. (3) Pigmented and nonpigmented hair, (4) childhood and elderly. MATERIALS AND METHODS: Hair fibers were mounted in tensile strength testing machine Zwick/Roell Z010 and gradual force was administered. The elongation of hair fiber in mm and the maximum force required to break the hair strand were recorded for each fiber. RESULTS: Elasticity of the children's hair was more than the elasticity of adult (P = 0.05) although tensile strength in children hair was not statistically significant (>0.05). Similarly, the tensile strength was more among those who regularly consumed nonvegetarian food but the difference was not statistically significant (P > 0.05). There was no statistically significant difference in other groups (P > 0.05). CONCLUSION: Elasticity in children hair is statistically more than elderly hair although there is no significant change in tensile strength.

Lumbar lipomeningomyelocele associated with multiple café au lait spots: a case report.

We report on a child with several café au lait spots in association with a lumbar lipomeningomyelocele as an apparently new association. Cutaneous markers, the identification of which plays a crucial role in the early diagnosis and management of spinal malformations, can accompany occult spinal dysraphism. Herein we report a case of lumbar lipomeningomyelocele associated with an overlying café au lait spot that served as a marker of occult spinal dysraphism. The patient also had segmental café au lait spots on the face, making the association unique.

Epidemiological pattern of psoriasis, vitiligo and atopic dermatitis in India: Hospital-based point prevalence.

BACKGROUND: The knowledge of the prevalence of common dermatoses will be useful for optimum use of valuable resources of the country. AIM: The aim of the study is to determine the pattern and prevalence of psoriasis, vitiligo and atopic dermatitis (AD) in India. MATERIALS AND METHODS: This was a hospital-based study conducted on a single day in one medical college each in four zones of India. RESULTS: The point prevalence of dermatological cases was 9.25%. The point prevalence of psoriasis, vitiligo and AD were 8%, 9.98% and 6.75% respectively. Chronic plaque type psoriasis was the most common (50%) clinical pattern. The most common site of involvement of psoriasis was the palms. Stable type of vitiligo was common which accounted for 65.21%. Lower lip was involved in 75% of mucosal vitiligo. Lower limbs were the most common site of onset of vitiligo. AD was most prevalent in the first decade (40.7%). Personal history of atopy was present in (59.5%) patients. Dry skin was present in 92.5% of patients. CONCLUSIONS: Our data correlates with previous hospital-based prevalence studies of psoriasis, vitiligo and AD.

Efficacy and safety of itolizumab, a novel anti-CD6 monoclonal antibody, in patients with moderate to severe chronic plaque psoriasis: results of a double-blind, randomized, placebo-controlled, phase-III study.

BACKGROUND: Itolizumab, a humanized monoclonal antibody to CD6, is a novel therapeutic agent evaluated in chronic plaque psoriasis. OBJECTIVE: We sought to assess the safety and efficacy of itolizumab in moderate to severe chronic plaque psoriasis. METHODS: A total of 225 patients were randomized (2:2:1) to 2 different itolizumab arms (A or B; A = 4-week loading dose of 0.4 mg/kg/wk followed by 1.6 mg/kg every 2 weeks; B = 1.6/mg every 2 weeks) or placebo. At week 12, the placebo arm was switched to 1.6 mg/kg itolizumab every 2 weeks. The primary end point was the proportion of patients with at least 75% improvement in Psoriasis Area and Severity Index score at week 12. RESULTS: At week 12, 27.0% in arm A (P = .0172 vs placebo), 36.4% in B (P = .0043 vs placebo), and 2.3% in the placebo arm had at least 75% improvement in Psoriasis Area and Severity Index score. At week 28, the proportion with at least 75% improvement in Psoriasis Area and Severity Index score was comparable: 46.1%, 45.5%, and 41.9% for A, B, and placebo, respectively. In weeks 1 to 12, the incidence of all adverse events was comparable across arms (A, 43%; B, 38%; placebo, 47%) and the incidence of infections was not greater than placebo (11.1%, 8.9%, and 18.6% for A, B, and placebo). LIMITATIONS: No active comparator is a limitation. CONCLUSIONS: Itolizumab is an effective and well-tolerated novel biological therapy in moderate to severe psoriasis.

Fractional-targeted phototherapy.

Targeted ultraviolet B phototherapy is used in the treatment for localized variants of psoriasis. We present two cases in which we compared the efficacy of lite spot and lite brush in the treatment of psoriasis and vitiligo.