Nail changes in casted and braced clubfoot: A preliminary study.

BACKGROUND: The study aimed at finding whether there are any nail changes specific to treatment in clubfoot. METHODS: Sixty new, 26 undergoing serial corrective casting, and 247 clubfoot patients using foot abduction braces were prospectively studied. The casted and braced group formed the basis of the study to observe nail changes, if any. The new patients and opposite normal foot (in unilateral casted cases) were taken as controls. OBSERVATIONS: Acute paronychia, ingrown toe nail, onychoshizia, onychorrhexis, nail plate concavity, latent onychomadesis, and distal onycholysis were observed in feet undergoing corrective casting and bracing. Micronychia, malalignment and thinning of nail plate were the observed congenital nail anomalies. CONCLUSIONS: Nail changes in clubfeet are not infrequent. Certain nail changes might be etiologically linked to casting and bracing. Some of nail changes might require urgent medical care.

Is frictional lichenoid dermatitis a minor variant of atopic dermatitis or a photodermatosis.

CONTEXT: Frictional lichenoid dermatitis. BACKGROUND: Frictional lichenoid dermatitis (FLE) is an entity that is probably under diagnosed and has been variably associated with either friction and/or atopy with a distinctive seasonal variation. AIMS AND OBJECTIVES: To study correlation of FLE with UV index and to assess its association with atopic dermatitis. MATERIALS AND METHODS: A cross sectional analysis of children with FLE was done, over a period of 6 years in two tertiary hospitals. A detailed history and examination was done to assess the features of atopic dermatitis. The number of cases seen per month was compared with the mean monthly UV index. Two-tailed significance tests using Pearson's coefficient of correlation and T-test were used to interpret the data. (P < 0.05). RESULTS: One hundred seventy-four patients were studied using the UKC criterion 17.2% of the patients had AD while xerosis (40.3%) was the predominant cutaneous finding. The number of patients seen in summer was more than in winter (P < 0.05) but there was no statistical difference between the cases in winter and spring. There was a significant correlation of the number of cases per month with UV index (P = 0.019). Almost 42% of patients gave a history of recurrence. CONCLUSIONS: FLE is probably not associated with atopic dermatitis and is likely to be related to the ambient UV index though a larger cohort with meticulous follow up may be needed to draw a final conclusion. STATISTICAL ANALYSIS USED: The Pearson's coefficient of correlation was used for comparing the cases per month with the UV index. The tests of hypothesis used included the paired T-tests. F-test of variance, Welch test, Wilcoxon rank sum test and the Kolmogorov-Smirnov Test. P < 0.05 was considered significant.

Linear Nevoid Epidermolytic Hyperkeratosis Localized to the Sole.

The term epidermolytic hyperkeratosis, used synonymously for bullous ichthyosiform erythroderma, is in fact a histopathologic reaction pattern. Clinically, it may present as a generalized, localized, or palmoplantar variant. Generalized epidermolytic hyperkeratosis is a genetic disorder, while localized epidermolytic hyperkeratosis occurs sporadically as a result of mosaicism. The authors report a case of linear nevoid epidermolytic hyperkeratosis localized to the sole.

Large multifocal cutaneous hemangioma along lines of Blaschko with cardiac failure treated with propranolol.

Hemangiomas are classified as focal or segmental according to the morphology and distribution of lesions. Congestive cardiac failure is frequently encountered in diffuse hepatic hemangiomas due to high-volume shunting and rarely in hemangiomas confined to the skin. We report here the case of a large multifocal hemangioma along the lines of Blaschko with high-output cardiac failure, with improvement in cutaneous and hemodynamic symptoms after propranolol therapy. Presentation along the lines of Blaschko raises the possibility of hemangiomas arising as a result of mosaicism.

Luliconazole for the treatment of fungal infections: an evidence-based review.

Luliconazole is an imidazole antifungal agent with a unique structure, as the imidazole moiety is incorporated into the ketene dithioacetate structure. Luliconazole is the R-enantiomer, and has more potent antifungal activity than lanoconazole, which is a racemic mixture. In this review, we summarize the in vitro data, animal studies, and clinical trial data relating to the use of topical luliconazole. Preclinical studies have demonstrated excellent activity against dermatophytes. Further, in vitro/in vivo studies have also shown favorable activity against Candida albicans, Malassezia spp., and Aspergillus fumigatus. Luliconazole, although belonging to the azole group, has strong fungicidal activity against Trichophyton spp., similar to that of terbinafine. The strong clinical antifungal activity of luliconazole is possibly attributable to a combination of strong in vitro antifungal activity and favorable pharmacokinetic properties in the skin. Clinical trials have demonstrated its superiority over placebo in dermatophytosis, and its antifungal activity to be at par or even better than that of terbinafine. Application of luliconazole 1% cream once daily is effective even in short-term use (one week for tinea corporis/cruris and 2 weeks for tinea pedis). A Phase I/IIa study has shown excellent local tolerability and a lack of systemic side effects with use of topical luliconazole solution for onychomycosis. Further studies to evaluate its efficacy in onychomycosis are underway. Luliconazole 1% cream was approved in Japan in 2005 for the treatment of tinea infections. It has recently been approved by US Food and Drug Administration for the treatment of interdigital tinea pedis, tinea cruris, and tinea corporis. Topical luliconazole has a favorable safety profile, with only mild application site reactions reported occasionally.

Premature graying of hair.

Premature graying is an important cause of low self-esteem, often interfering with socio-cultural adjustment. The onset and progression of graying or canities correlate very closely with chronological aging, and occur in varying degrees in all individuals eventually, regardless of gender or race. Premature canities may occur alone as an autosomal dominant condition or in association with various autoimmune or premature aging syndromes. It needs to be differentiated from various genetic hypomelanotic hair disorders. Reduction in melanogenically active melanocytes in the hair bulb of gray anagen hair follicles with resultant pigment loss is central to the pathogenesis of graying. Defective melanosomal transfers to cortical keratinocytes and melanin incontinence due to melanocyte degeneration are also believed to contribute to this. The white color of canities is an optical effect; the reflection of incident light masks the intrinsic pale yellow color of hair keratin. Full range of color from normal to white can be seen both along individual hair and from hair to hair, and admixture of pigmented and white hair is believed to give the appearance of gray. Graying of hair is usually progressive and permanent, but there are occasional reports of spontaneous repigmentation of gray hair. Studies evaluating the association of canities with osteopenia and cardiovascular disease have revealed mixed results. Despite the extensive molecular research being carried out to understand the pathogenesis of canities, there is paucity of effective evidence-based treatment options. Reports of repigmentation of previously white hair following certain inflammatory processes and use of drugs have suggested the possibility of cytokine-induced recruitment of outer sheath melanocytes to the hair bulb and rekindled the hope for finding an effective drug for treatment of premature canities. In the end, camouflage techniques using hair colorants are outlined.

Tuberculous dactylitis presenting as paronychia with pseudopterygium and nail dystrophy.

Scrofuloderma is a type of secondary tuberculosis (TB) arising from contiguous involvement of skin by an underlying tuberculous focus in the lymph nodes or bones. It may occasionally be the presenting feature of osteoarticular TB. Tuberculous dactylitis is the involvement of the small tubular bones of the hands and feet, and most cases occur in children younger than 6 years of age. Fingers are more commonly involved than toes, and painless swelling of a digit is the usual presentation. Involvement of the toes is rare, with only a few reported cases. The indolent clinical course leads to a delay in diagnosis, and bone shortening with joint deformity is the usual outcome, especially in tuberculous dactylitis affecting the foot. We report here a case of tuberculous dactylitis of the great toe and scrofuloderma affecting the nail fold presenting as painless paronychia with pseudopterygium and nail dystrophy. Nail involvement led to an early presentation and timely diagnosis and treatment before progression to permanent bone or joint deformity.

Trichophyton tonsurans induced recurrent onychomadesis in a very young infant.

Onychomadesis, or nail shedding, is rarely seen in children and can be due to stress, systemic illnesses, trauma, and drug therapy or may be idiopathic. Fungal infection of the nail is only rarely reported as a cause of onychomadesis. We present here a case of Trichophyton tonsurans-induced onychomycosis and resultant onychomadesis in a 9-month-old boy with onset of lesions at 2 weeks of life.

Cutaneous vascular lesions and their management in Indian setting.

Indian skin with its broad range of skin color and complexion differs in the presentation and management of cutaneous vascular lesions. Common congenital and acquired vascular lesions are discussed with respect to the epidemiology, clinical presentation, and management strategies in an Indian setting. An effort has been made to review Indian case reports and studies of cutaneous vascular lesions, potential possible modification in the conventional treatment considering resource constraints, cultural practices, availability and cost-effectiveness of the laser and light sources, camouflage techniques, and sclerotherapy. The review concludes with emphasis on the need of availability of cost-effective, quality equipment customized to Indian skin and quality studies and trials for the management of cutaneous vascular lesions in an Indian setting.

Onychomycosis: Diagnosis and management.

Onychomycosis is a common nail ailment associated with significant physical and psychological morbidity. Increased prevalence in the recent years is attributed to enhanced longevity, comorbid conditions such as diabetes, avid sports participation, and emergence of HIV. Dermatophytes are the most commonly implicated etiologic agents, particularly Trichophyton rubrum and Trichophyton mentagrophytes var. interdigitale, followed by Candida species and non dermatophytic molds (NDMs). Several clinical variants have been recognized. Candida onychomycosis affects fingernails more often and is accompanied by paronychia. NDM molds should be suspected in patients with history of trauma and associated periungual inflammation. Diagnosis is primarily based upon KOH examination, culture and histopathological examinations of nail clippings and nail biopsy. Adequate and appropriate sample collection is vital to pinpoint the exact etiological fungus. Various improvisations have been adopted to improve the fungal isolation. Culture is the gold standard, while histopathology is often performed to diagnose and differentiate onychomycosis from other nail disorders such as psoriasis and lichen planus. Though rarely used, DNA-based methods are effective for identifying mixed infections and quantification of fungal load. Various treatment modalities including topical, systemic and surgical have been used.Topically, drugs (ciclopirox and amorolfine nail lacquers) are delivered through specialized transungual drug delivery systems ensuring high concentration and prolonged contact. Commonly used oral therapeutic agents include terbinafine, fluconazole, and itraconazole. Terbinafine and itraconazole are given as continuous as well as intermittent regimes. Continuous terbinafine appears to be the most effective regime for dermatophyte onychomycosis. Despite good therapeutic response to newer modalities, long-term outcome is unsatisfactory due to therapeutic failure, relapse, and reinfection. To combat the poor response, newer strategies such as combination, sequential, and supplementary therapies have been suggested. In the end, treatment of special populations such as diabetic, elderly, and children is outlined.

Comparison of cutaneous manifestations in chronic kidney disease with or without dialysis.

PURPOSE: To study and compare dermatological manifestations in patients with various stages of chronic kidney disease (CKD) and end stage renal disease (ESRD), undialysed and dialysed, in a developing country. STUDY DESIGN: 200 patients were recruited, 50 each in stages 3, 4 and 5 CKD (undialysed) and 50 in stage 5 undergoing maintenance haemodialysis (MHD) for at least 1 month. Patients in stages 3 and 4 constituted pre-ESRD while stage 5 (both dialysed and undialysed) formed the ESRD group. Detailed cutaneous examination was done for all patients and dermatological manifestations were compared among various study groups. RESULTS: 96% of patients had at least one dermatological manifestation. Xerosis was most common and was observed in 72% of patients, followed by pigmentation (50%), pruritus (36%), infections (29%), markers of skin ageing (13%), half-and-half nail (28%), and absent lunula (22%). Perforating disorders (3%), bullous disorders (2%), and nephrogenic systemic fibrosis (1%) were encountered less often. Local complications of dialysis occurred in 64% patients on MHD. Diffuse pigmentation and skin pallor were seen more commonly as compared to findings reported in the west. The frequency of most cutaneous manifestations was similar between dialysed and undialysed patients with ESRD. Xerosis, pigmentation, and pruritus were more frequent in patients with severe disease, and mean duration of disease was significantly higher for patients with pigmentation, pruritus, and half-and-half nail. Longer duration on MHD was associated with greater pigmentation and pruritus. CONCLUSION: Dermatological manifestations increase with increasing duration and severity of renal disease. Dialysis may in turn often perpetuate many of these cutaneous complaints. Recognition and management of some of these dermatological manifestations may vastly reduce the morbidity and improve the cutaneous outcome in these patients.

Detection of virulence genes in Staphylococcus aureus isolated from paper currency.

BACKGROUND: Infection with Staphylococcus aureus was initially considered a major problem in hospitals, but over the last few decades the incidence of community-acquired infection has also increased. Paper currency has recently been identified as another mode of spread by which community-acquired S. aureus infection may be transmitted, since paper currency is frequently transferred from one person to another. In the present study, S. aureus strains were isolated from paper currency and screened to detect virulence-associated genes. METHODS: Paper currency was collected randomly from operators in mutton shops, vegetable shops, hospitals, medical stores, snacks corners, and restaurants in the two cities of India, Dehradun and Delhi. Samples were screened for pathogenic S. aureus by various biochemical assays. Three isolates were used to study the survival of S. aureus on paper currency. Virulence genes were amplified by PCR. Antibiotic susceptibility was determined against nine antibiotics by the disk diffusion method. RESULTS: Sixty-seven isolates of Staphylococcus aureus were isolated from paper currency from the two Indian cities. The maximum number of isolates was recovered from hospitals, followed by mutton shops, and the minimum from restaurants. The test isolates could survive on paper currency for eight days under in vitro conditions (27 degrees C temperature and 30% relative humidity). A set of four virulence genes viz. cna (16 isolates), icaA (19 isolates), hlg (21 isolates), and sdrE (18 isolates) was amplified using gene-specific primers. Only eight isolates possessed all four virulence genes. Antimicrobial susceptibility tests showed that those isolates having all the tested virulence genes were more resistant. CONCLUSIONS: This study clearly suggests that paper currency can serve as a carrier for the spread of resistant bacterial pathogens.

A novel congenital ichthyosiform syndrome with associated panhypopituitarism, corneal opacities and mental retardation.

A 15-year-old male presented with ichthyosis since infancy with panhypopituitarism, short stature and knock-knees, delayed puberty, high scrotal retractile testes, mental retardation and corneal opacities. He developed recurrent tinea capitis and tinea corporis. The clinical symptomatology indicates that this case cannot be considered as a subtype of inherited ichthyosis group, but suggests a new syndrome as a separate nosologic entity. Two previously reported cases with possibly the same syndrome also had ichthyosis associated with variable endocrinopathy. Thorough endocrinological evaluation and appropriate intervention in patients of ichthyosis with short stature may reduce the morbidity associated with retarded skeletal growth and gonadal maturation.