Nail Society of India Recommendations for Treatment of Onychomycosis in Special Population Groups.

Onychomycosis (OM) is a difficult-to-treat condition, especially considering the limited armamentarium of antifungal drugs, need for prolonged treatment, and poor compliance. This problem is further confounded while treating OM in special populations such as children, elderly, immunosuppressed patients, pregnant or lactating women, and patients with chronic liver or kidney disease. In the absence of standardized treatment guidelines, the antifungal therapy is either withheld or compromised, as it is largely governed by personal preferences or based on anecdotal reports. Hence, an expert group of the Nail Society of India worked towards drafting guidelines based on established literature and inputs from experts, with practical recommendations for the treatment of onychomycosis in special population groups. An extensive analysis of available English language literature on onychomycosis in special populations, published during a 10-year period (2014-2023 until date) was done. The available studies and reports were evaluated, cross-references read, and evidence compiled, graded, and discussed by the expert group to derive consensus recommendations for practice. The evidence and recommendations based on it are presented in a narrative format to guide treatment choices when dealing with population groups with special considerations.

Post Herpetic Itch Leading to Frictional Alopecia of Eyebrow and Scalp-A Hitherto Undescribed Phenomenon.

Post herpetic itch (PHI) is a less commonly reported sequela of herpes zoster. It can begin upon the resolution of the lesions or several weeks later. PHI is neuropathic in nature and is said to be caused by neural injury in the form of demyelination of itch-transmitting nerve fibers in the skin. The majority of PHI resolves over weeks to months with symptomatic treatment. We report a case of PHI resulting in frictional alopecia of eyebrows and scalp due to frequent rubbing of the skin and hairs secondary to bothersome neuropathic itch.

Nail Society of India (NSI) Recommendations for Pharmacologic Therapy of Onychomycosis.

Onychomycosis (OM) is the commonest cause of dystrophic nails, responsible for upto 50% of cases. Apart from significantly damaging the nails, quality of life, and self-image of the sufferer, it also acts as a reservoir of fungal infections carrying important implications for emerging recalcitrant dermatophytoses. Treatment of OM is based on guidelines released almost a decade back, in addition to published literature and personal preferences. Hence, an expert group of nail society of India (NSI) worked towards drafting these guidelines aimed at compiling recommendations for pharmacologic treatment of OM, based on scientific evidence, along with practical experience. The group did an extensive analysis of available English language literature on OM published during the period 2014-2022. The evidence compiled was graded and discussed to derive consensus recommendations for practice. Special focus was placed on combination therapies and adjunct therapies, including experience of members, to improve treatment outcomes.

Cutaneous tuberculosis. Part II: Complications, diagnostic workup, histopathologic features, and treatment.

Despite the availability of effective treatment regimens for cutaneous tuberculosis, challenges to disease control result from delayed diagnosis, infection with multidrug-resistant mycobacterial strains, and coinfection with HIV. Delayed diagnosis can be mitigated when dermatologists are sensitized to the clinical signs and symptoms of infection and by the incorporation of appropriate diagnostic tests. All cases of cutaneous tuberculosis should be confirmed with histopathology and culture with or without molecular testing. In each case, a thorough evaluation for systemic involvement is necessary. Mycobacteria may not be isolated from cutaneous tuberculosis lesions and therefore, a trial of antituberculosis treatment may be required to confirm the diagnosis. The second article in this 2-part continuing medical education series describes the sequelae, histopathology, and treatment of tuberculosis.

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.

Radiological Imaging of Nail Disorders (PART II) - Radiological Features of Nail Disease.

We have seen that radiological techniques like digital x-ray, high-frequency ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) have their unique roles in assessing a complex anatomical structure like the nail unit. Broadly speaking, USG and MRI help evaluate soft tissue components well; while, radiographs and CT scans help assess bony lesions better. In the second part of this review, salient radiological features of various nail disorders, as seen on these modalities are detailed. The radiological features mostly play a supportive role and help rule out differential diagnoses. However, in some diseases like retronychia and some nail tumors, radiological findings help clinch the diagnosis. The diagnostic features as well as the investigative modality of choice for a particular disease are highlighted based on the best level of evidence (LoE) available. This narrative review includes both infectious and non-infectious nail unit diseases, with special emphasis on nail unit tumors.

Radiological Imaging in Nail Unit Disorders (Part I) - Modalities Used.

The nail unit is a unique skin appendage, capable of mounting only a limited number of reaction patterns to a variety of insults. This makes it difficult to diagnose many nail conditions based on clinical features alone. Thus, diagnostic modalities have an important role to play in nail disorders. Emphasis is placed on non-invasive diagnostic methods, of which, radiological imaging forms an important part; however, it is a field largely under-explored with very few studies and reports available in the literature. This could be due to the problems encountered in nail unit radiology including its small size, complex anatomy, requirement for special high-frequency probes to reliably evaluate superficial structures, and non-familiarity with nail unit radiological features even amongst trained radiologists. Nevertheless, it plays a useful role in diagnosing nail disorders (especially tumors), localizing the changes, exploring differential diagnoses, estimating prognosis, and planning management. This article is aimed at collating scientific data pertaining to various radiological modalities used in the diagnosis of nail diseases. The advantages and limitations of various imaging techniques used for evaluating the nail unit, including digital radiographs, high-frequency ultrasound, ultrasound doppler (USD), computed tomography (CT), and magnetic resonance imaging (MRI), are discussed in the first part. The second part will discuss the features of common and uncommon nail diseases.

Spectrum of Mucocutaneous Reactions to COVID-19 Vaccination: A Report from a Web-Based Study from India.

Background: With the COVID-19 vaccination taking stride all across the globe, there are multiple reports of vaccine-induced adverse reactions (cutaneous and systemic). Objectives: To study the frequency and characteristics of mucocutaneous reactions to COVID-19 vaccines. Methods: An online questionnaire-based study was performed among the recipients of COVID-19 vaccines. Results: Majority (73.6%) of the responders had received the Covishield vaccine (AstraZeneca-Oxford), while 26.4% had been vaccinated with Covaxin (Bharat Biotech-ICMR). One or more post-vaccination mucocutaneous effects were experienced in 87 (19.6%) participants. Vaccine-associated mucocutaneous changes were observed in 19.7% and 22.2% of individuals who received Covishield and Covaxin, respectively. Local injection site reaction was the predominant mucocutaneous finding, followed by urticarial rash, exacerbation of preexisting dermatoses, morbilliform rash, apthous ulcers, pityriasis rosea like eruption, telogen effluvium, herpes zoster, purpuric rash, erythema multiforme and others. Anaphylaxis was reported in three individuals. However, fatality was not reported in any of the vaccine recipients. Intergroup assessment of parameters with respect to type of vaccine was found to be insignificant. Conclusion: Majority reported mild and self-limiting reactions. This outcome should not discourage the common man in getting vaccinated.

Clinicoepidemiological characteristics of cutaneous tuberculosis in 1458 Indian patients: a retrospective analytical study from a tertiary care center.

BACKGROUND: Tuberculosis (TB) has been one of the most challenging infectious diseases globally. Cutaneous tuberculosis (CTB) accounts for 0.5-2% of extrapulmonary TB and is often missed owing to its varying morphology and paucibacillary nature. METHODS: In this retrospective analytical study, we share our 22-year experience to describe the clinicoepidemiological features and treatment response of CTB in 1458 Indian patients. In each patient, detailed history was followed by clinical examination, hematological and biochemical investigations, Mantoux testing, chest x-ray, and other specialized investigations to detect coexisting systemic foci. Clinical diagnosis of CTB was confirmed on histopathology/cytology and response to standard antitubercular treatment (ATT). All details were recorded on a predesigned proforma. RESULTS: Of 1458 eligible patients, 803 were children. The mean disease duration was 15.3 months. Lupus vulgaris (40.4%) was the most common clinical variant, followed by scrofuloderma (32.7%) and lichen scrofulosorum (15.2%). Other variants included tuberculosis verrucosa cutis, gumma, tuberculids, and inoculation TB. Multiple clinical variants were observed in 3.6% of patients. A total of 41.4% of patients had coexistent systemic foci; in lymph nodes (50.4%), lungs (35.6%), bone (10.3%), and abdomen (5.8%). TB foci were also observed at uncommon locations like the eye, central nervous system, and genital organs. Treatment response to ATT was favorable in 99.2%. INTERPRETATION: The burden of CTB still persists in developing countries. The diagnosis is often missed due to the wide spectrum of clinical and histological presentations. Awareness among clinicians of varying aspects of CTB is of paramount importance for early diagnosis and management and will significantly prevent morbidity and disease complications.

Nail-fold capillaroscopy for the dermatologists.

Nail fold is one of the most accessible sites for studying changes in the microcirculation in various microangiopathies. The characterization of changes in microvasculature can provide useful clues towards the diagnosis and prognosis of a disease. The diagnostic utility of nail fold capillaroscopy has improved and expanded over the past couple of decades. Beyond connective tissue diseases, it is now explored for its role in various systemic and dermatological diseases. Incorporation of nail-fold capillaroscopy in the diagnostic criteria of systemic sclerosis has generated interest among dermatologists. The current review is aimed at providing knowledge about nail-fold capillaroscopy to dermatologists. For the purpose of review, a PubMed search was done using the keywords "nail fold capillaries" and "nail fold capillaroscopy". All the articles were retrieved and classified into reviews and clinical studies of various types. The final data were then analyzed and presented in a narrative fashion.

International Dermoscopy Society criteria for non-neoplastic dermatoses (general dermatology): validation for skin of color through a Delphi expert consensus.

BACKGROUND: The International Dermoscopy Society (IDS) recently released a set of five basic dermoscopic parameters (vessels, scales, follicular findings, "other structures," and specific clues) encompassing a total of 31 subitems to standardize the use of dermoscopy in non-neoplastic dermatoses, yet they have been developed taking into account Caucasian/Asian skin, with consequent possible limitations if used in dark skin. OBJECTIVES: To validate the abovementioned criteria for the use in dark-skinned patients (phototypes IV-VI) through an expert consensus. METHODS: The two-round Delphi method was adopted, with an iterative process consisting of two rounds of email questionnaires. Potential panelists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses in skin of color. RESULTS: Twenty-two panelists took part in the validation process. All of the five originally proposed parameters and subitems reached agreement during the first round, aside from "follicular red dots." Additionally, during round 1, five new subitems were proposed (perifollicular scales distribution, follicular openings obliteration, broken hairs, eccrine pigmentation, and eccrine ostia obliteration), along with the possibility to change the denomination of parameter 3 (from "follicular findings" to "follicular/eccrine findings") and split it into two subparameters ("follicular findings" and "eccrine findings"). All such proposals reached agreement during the second round and therefore were included in the final list, for a total of 37 items. CONCLUSIONS: Although nearly all the dermoscopic criteria originally proposed by the IDS are applicable even to darker phototypes, several additional variables need to be assessed.

Mucoscopy of Oral Leukoplakia: A Case Series.

The application of a dermoscope in the study of mucosal pathologies is increasingly gaining importance. An easy, noninvasive characterization of pathological changes serves as an aid to dermatologists, sometimes even obliviating the need for histopathology. The aim of the present case series was to describe the mucoscopic features of histologically proven oral leukoplakia. Five consecutive cases of histologically proven oral leukoplakia were included for mucoscopy. Polarized mucoscopy shows white-to-pink structureless areas (100%), intervening pink lines (80%), and surface corrugations (60%). The periphery of the lesions showed white clods (100%) and dotted vessels with irregular arrangement (60%).