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   Table of Contents - Current issue
September-October 2019
Volume 10 | Issue 5
Page Nos. 503-616

Online since Wednesday, August 28, 2019

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Oral tofacitinib: Contemporary appraisal of its role in dermatology Highly accessed article p. 503
Sidharth Sonthalia, Parul Aggarwal
Tofacitinib, an oral Janus kinase inhibitor (Jakinib), is an emerging treatment modality whose well-established efficacy in systemic inflammatory diseases is now being actively explored for cutaneous disorders (arising due to the patient's dysimmune responses) that are not responding to and/or sustaining intolerable adverse effects with the classical immunosuppressives and other targeted therapies such as the biologics. The most common dermatoses for which oral as well as topical Jakinibs such as tofacitinib have been evaluated and are being used albeit as an off-label indication include psoriasis, psoriatic arthritis, alopecia areata, vitiligo, and atopic dermatitis. This article provides a succinct review on the current status of oral tofacitinib in dermatology through literature search of PubMed database and stresses on the need for further evidence generation to define the drug's place in the therapeutic arsenal of dysimmune cutaneous disorders.
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Comparative analysis of epidemiological data as well as quality of life in patients having hand eczema vis-à-vis foot eczema p. 519
Prachi V Agrawal, Ajay Kumar, Yugal K Sharma, Mahindra Deora, Rahul H Ranpariya
Context: Eczema of hand or foot though not life-threatening, not only impacts daily activities and work productivity adversely, but also impairs interpersonal relationships. Materials and Methods: Cross-sectional study of 100 outpatients of hand and foot eczema at a tertiary care teaching institute. Epidemiological data was collated and quality of life (QoL) evaluated by dermatology life quality index (DLQI) score. Results: Forty seven had hand eczema, 45; foot eczema and 8; both. Peak incidence of hand eczema (38.2%) was in fourth decade and foot eczema (33.3%), fifth decade. Hand eczema was more frequent in females (32; 68%) and foot eczema in males (32; 71.1%). Hand eczema was more common among housewives (14; 29.7%) and foot eczema among manual labourers (26; 57.7%). A persistent course was seen in foot (44; 83%) whereas recurrent course in hand eczema (21; 38.1%). Aggravation on contact with irritants/allergens was associated more with hand (32; 58.1%) than with foot eczema (18; 33.9%). Association with atopy was not significant. Substance abuse was associated more with foot eczema (25; 47.1%). Impairment in QoL was significantly higher in hand eczema (mean DLQI, 16.33) as compared to foot eczema (12.83). Conclusion: Hand eczema prevalent among females showed a high rate of recurrence whereas foot eczema in males, has a persistent course. Atopy is not significantly associated. The impairment in QoL is much greater in hand eczema as compared to foot eczema. The studies on comparative analysis of hand vis-à-vis foot eczema do not appear to exist in literature whereas studies of QoL impairment on hand eczema are abound.
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A cross-sectional observational study of geriatric dermatoses in a Tertiary Care Hospital of Northern India p. 524
Reetu Agarwal, Loknandani Sharma, Ajay Chopra, Debdeep Mitra, Neerja Saraswat
Introduction: Geriatric dermatoses are one of the most common reasons for day-to-day consultation in the elderly. Over the past few years, understanding of the pathophysiology of skin changes in the geriatric age group has improved and has paved the way for better therapeutic options. There are only a few studies conducted in India about the geriatric dermatoses. This article reviews the various physiological and pathological changes of aging, dwelling on the role of intrinsic and extrinsic factors in the pathogenesis of aging skin thus better understanding of this emerging branch in dermatology leading to enhance resource management for elderly population. Materials and Methods: This is a cross-sectional observational study carried out on 500 consecutive patients aged 60 years and above in Department of Dermatology of a Tertiary care hospital of Northern India after meeting the inclusion and exclusion criteria. Results: Out of 500 patients studied with male to female ratio of 1.4, wrinkles followed by cherry angiomas were the most common physiological cutaneous manifestations, and infective dermatoses followed by allergic contact dermatitis were the most common pathological conditions seen. Few rare cases were also seen during the study such as cutis marmorata, delusion of parasitosis, and sweet syndrome in case of acute myeloid leukemia. Conclusion: Geriatric dermatology is an emerging branch in dermatology, and an update on this, will go a long way to effectively manage these patients. A thorough knowledge of the epidemiology as well as gender distribution of dermatological diseases in geriatric population in the tertiary care hospital will help in assessing health status and health care needs related to skin for better allocation of resources, distribution of material and manpower, and help health care providers in better decision-making resulting in higher clientele satisfaction.
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Can dermoscopy serve as a diagnostic tool in dermatophytosis? A pilot study p. 530
Yasmeen Jabeen Bhat, Abid Keen, Iffat Hassan, Insha Latif, Safia Bashir
Background: Dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders. Aim: The purpose of the study was to describe the dermoscopic findings in various dermatophytosis. Materials and Methods: This cross-sectional study included 100 clinically diagnosed tinea infections of skin, hair, and nails, which were evaluated using a dermoscope (Dermlite 3 gen DL3N, California USA, 10x). Results: Among 100 patients of dermatophytosis, 69 were males and 31 females. The maximum number of patients had tinea corporis, followed by tinea cruris and tinea capitis. Dermoscopic findings noted in cases of tinea corporis included diffuse erythema, follicular micropustules, and brown spots surrounded by a white-yellowish halo, broken hair, wavy hair, and rare, morse code hair. Dermoscopy of tinea capitis depicted comma hairs, corkscrew hairs, zigzag hairs, and morse code hairs. Proximal jagged edge, spikes, and longitudinal striations were present in the cases of onychomycosis. Dermoscopy of tinea incognito yielded morse code hairs, follicular micropustules, and easily deformable hairs that look weakened and transparent and show unusual bends. Limitations: Dermoscopic findings were not correlated to fungal culture. Conclusion: Dermoscopy can be used as a fast, inexpensive, and noninvasive diagnostic tool to enhance diagnosis of cutaneous fungal infections.
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Dermoscopic features of lower lip squamous cell carcinoma: A descriptive study p. 536
Ömer Faruk Elmas, Mahmut Sami Metin, Asuman Kilitçi
Aim: Dermoscopic features of cutaneous squamous cell carcinoma (SCC) have been well described; however, there are a few studies focused on the dermoscopic aspect of lip SCC. In this study, we aimed to identify dermoscopic findings of lower lip SCC. Materials and Methods: The clinical and histopathologic features, dermoscopic images, and demographic data of the patients with histologically approved lip SCC were retrospectively evaluated. Results: A total of 10 lesions were enrolled in the study. Milky red structureless background (100%) and keratin scale (100%) were present in all the lesions. Blood spots on thick keratin scale were observed in eight lesions. Seven lesions showed white structureless areas. Two lesions exhibited ulceration and one of the lesions had structureless brown pigmentation. The most common vascular pattern observed was polymorphous vascular pattern (60%). Conclusion: White and milky red structureless areas, blood spots on thick keratin scale, and polymorphous vascular pattern are the main dermoscopic clues to lip SCC. The presence of these findings should direct the clinician to the possibility of SCC. The dermoscopic findings observed may also reflect histological grade of the lesion.
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Histological evaluation of acquired dermal macular hyperpigmentation p. 542
Sarita Sasidharanpillai, Aparna Govindan, Kidangazhi yathmana Ajithkumar, Saranya T Mahadevan, Valiyaveettil Bindu, Anza Khader, Puthen Parambath Sathi
Context: An umbrella term, acquired dermal macular hyperpigmentation (ADMH), has been proposed to denote conditions including ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus, and idiopathic macular eruptive pigmentation. Aims: To classify the patients manifesting ADMH on the basis of histology. Settings and Design: In this retrospective, cross-sectional study, histology specimens of patients of ADMH, who underwent skin biopsy in our institution from 1.1 2015 to 31.12.2017, were included after obtaining ethical clearance. Materials and Methods: The histology specimens of patients of ADMH were reviewed by the pathologist and classified. Clinical features of individual patient were collected from previous records and the data analyzed. Statistical Analysis Used: Pearson's Chi-square test was used to determine significance of association between age of onset and duration of pigmentation with histology type. Results: Three patterns of histology were identified in the study group (17 males and 13 females). Type 1: Basal cell degeneration and moderate to dense inflammation (12 patients, 40%), type 2: Significant pigment incontinence and sparse inflammation without basal cell degeneration, (12 patients, 40%), and type 3: sparse inflammation without basal cell degeneration or significant pigment incontinence (six patients, 20%). Statistically significant association was noted between age of onset of pigmentation and histology type (P value, 0.02). Limitations: Main limitation was the small sample size. Conclusions: Prospective studies evaluating the clinical progression and dermoscopy features and analyzing serial biopsies of ADMH patients may confirm whether the histology patterns observed represent different stages of same disease process or are different entities.
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Pharmacovigilance of cutaneous adverse drug reactions among patients attending dermatology department at a Tertiary Care Hospital p. 547
Shweta Sharma, Dhanya Jayakumar, Dhanya S Palappalli
Context: Cutaneous adverse drug reactions (CADRs) are the most frequent of all manifestations of drug sensitivity that present with varied and diverse morphology and therefore, awareness about them is essential for diagnosis and prevention. Aims: To evaluate the clinical spectrum, morphology, causality, severity and preventability of cutaneous adverse drug reactions in a tertiary care hospital. Setting and Design: Descriptive study for six months in the Dermatology Department of a tertiary care hospital in Kerala. Methods and Materials: All patients of any gender and age who presented with visible skin lesions and were diagnosed or suspected cases of cutaneous adverse drug reactions were included in the study. All the relevant information was recorded using pre-structured proforma and ADR reporting form. Statistical Analysis: Data were analyzed using descriptive statistics. The quantitative variables were expressed as mean ± standard deviation and qualitative variables as frequencies and percentages. Odds ratio (OR) was calculated to assess the risk factors for severe cutaneous adverse drug reactions using SPSS 16. Results: Total 124 cutaneous adverse drug reactions were reported with mean age 39.22 ± 20.47 years, male:female ratio being 1:1.4. Most common cutaneous adverse drug reaction was maculopapular rash. Antibiotics accounted for maximum cases, of which beta-lactams were the most common. About 55.6% cutaneous adverse drug reactions occurred within 24 hours of drug administration. Mean hospital stay duration was 4.89 ± 6.23 days. Most reactions were either mild or moderate. Risk analysis revealed that concomitant use of more than one drug, delayed onset, oral route, more generalized area of involvement and medications prescribed for CNS indications were risk factors for severe cutaneous adverse drug reactions. All reactions were preventable. Majority got fully recovered. No fatality was observed. Conclusion: Identification and reporting of cutaneous adverse drug reactions reduces their future occurrences and encourages rational prescribing. The study emphasizes on having a deeper understanding of risk factors for serious cutaneous adverse drug reactions that may contribute significantly in improving their outcomes.
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Lichen planus and metabolic syndrome: Is there a relation? p. 555
Rohit Singla, PK Ashwini, Betkerur Jayadev
Background: Recent data suggests association of lichen planus (LP) with various systemic disorders. Relationship between LP and metabolic syndrome (MS) is not yet taken into account. MS has been associated with increased risk of cardiovascular diseases. Hence, earlier detection and treatment could potentially decrease mortality and improve the quality of life in these patients. Objectives: To find out the association of LP with MS. Materials and Methods: About 100 LP patients and 50 healthy adults were investigated for fasting blood glucose (FBS) and lipid profile. MS was diagnosed as per National Cholesterol Education Program's Adult Treatment Panel III guidelines. Results: Serum cholesterol, triglycerides, low density lipoprotein (LDL-C), and very low density lipoprotein (VLDL-C) values were significantly increased in cases as compared to controls (P < 0.05 in all). About 42% of patients showed raised FBS level as compared to 10% controls (P = 0.0003). MS was more prevalent in cases than in controls (43% versus 26% respectively, P= 0.045). Odds ratio was highest in FBS and waist circumference. Limitations: As the cases and controls are included from a local area, the result may differ from other parts of the world. Conclusion: Diabetes mellitus, dyslipidemia, and MS are seen more commonly in LP patients.
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Evaluation of a neurotoxin as an adjunctive treatment modality for the management of gummy smile p. 560
Neha Gupta, Sarvraj Kohli
Introduction: Excessive gingival display while smiling mars facial aesthetics, this condition is referred to as “gummy smile” (GS). Available literature suggests that Botulinum toxin type A (BTX-A) is effective in the management of excessive gingival display by denervating hyperfunctional muscles. This study was conducted to statistically assess the effects of BTX-A for the management of GS. Materials and Methods: A total of 10 patients between the ages of 18–27 years were selected for this study, they received BTX-A (Botox; Allergan, Irvine, CA, USA) injections for reduction of excessive gingival display at “Yonsei point” on both sides. Gingival display was measured as the vertical distance from the zenith of the gingiva of the upper right central incisor to the inferior border of the upper lip before beginning treatment (T0). The patients were then recalled after 15 days to measure the gingival display (T1). Standardized photographs to document changes were obtained at T0 and T1. Results: A statistically significant reduction in gingival display, while smiling was observed from T0 (7.5 ± 1.35 mm) to T1 (3.2 ± 0.91 mm) in all 10 patients (t = 16.5168, P value = 4.87, P < 0.05). Conclusions: Administration of BTX-A is recommended as an adjuvant to orthodontic treatment where the GS is caused due to hyperfunctional upper lip elevator muscles.
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Granulomatous variant of giant centrifugal miliaria profunda in a hypothyroid infant: A case report p. 564
Akansha A Chadha, Sunanda A Mahajan, Atul Dongre, Uday S Khopkar
The miliarias are a clinically heterogeneous group of diseases which occur when the free flow of eccrine sweat to the skin surface is impeded. Miliaria profunda is a variant with obstruction of the duct at or below the level of dermoepidermal junction. The giant centrifugal variant of miliaria profunda has been described in the past at the sites of occlusive tapes and in febrile patients. Thyroid hormone has a regulatory effect on the skin and its appendages and an association of hypothyroidism with this variant of miliaria profunda has not been described in the past. We report a case of giant centrifugal miliaria profunda in an infant with congenital hypothyroidism.
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Low-dose naltrexone-induced remission in Hailey–Hailey disease maintained in remission with topical combination of ketamine and diphenhydramine p. 567
Sidharth Sonthalia, Mahima Agrawal, Ankur Talwar, Mohamad Goldust
Recent anecdotal evidence suggests that oral low-dose naltrexone (LDN) is effective for Hailey–Hailey disease (HHD) but suffers the limitation of immediate relapse following cessation of the medication. With lack of safety data on long-term administration of LDN, we explored the utility of a topical diphenhydramine/ketamine (DK) cream in maintaining the remission achieved with LDN. A 42-year-old male with treatment-refractory HHD remitted with 5 mg naltrexone/day but relapsed on stopping the drug. Symptoms abated after restarting LDN. The impact of regular twice-a-day application of a specially formulated DK cream containing diphenhydramine (2% w/w) and ketamine (1% w/w) over the affected areas on maintenance of remission was explored till the next relapse. Our approach enabled dose reduction of naltrexone to 3 mg/day without loss of treatment benefit. After 3-month overlap of naltrexone and DK cream, withdrawal of naltrexone maintained remission with only the topical regime with no adverse effects till 4 months of follow-up. The use of topical agents with anti-inflammatory, antipruritic, antinociceptive, and naltrexone-mimicking properties merits exploration as an option to provide short but significant period of naltrexone-free maintenance of remission to patients with HHD.
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Lipedematous scalp with varied presentations: A case series of four patients p. 571
Priyadarshini Sahu, Bhavya Sangal, Surabhi Dayal, Sanjay Kumar
Lipedematous scalp (LS) is a rare cutaneous disorder of unknown etiology, characterized by significant thickening of subcutaneous tissue which results in a thick, boggy, scalp swelling. To the best of our knowledge, less than 50 cases are reported till date. Hereby, we present a total of four cases of LS, that is, two cases of LS and two cases of unusual associations of LS with alopecia areata and intradermal nevus. LS with intradermal nevus and alopecia areata are the first of its kind, not yet reported till date.So far, only two cases of LS had been reported from Indian population. Hence, our effort is to bring into notice this growing yet an uncommon condition in the Indian population.
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Cysticercosis cellulosae cutis: A forgotten entity p. 574
Kanagala Chowdary Neethu, Akshay Jain, S Haritha
Cysticercosis cellulosa cutis is caused by larval stage of Taenia solium. It most commonly affects central nervous system, muscle, and subcutaneous tissue. Here, we report a case of 70-year-old female who was misdiagnosed on ultrasound as abscess and was treated with no improvement. Later, she was diagnosed on FNAC as cutaneous cysticercosis. Hence, we report this case because of its uncommon clinical presentation and diagnostic difficulty.
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Dermatoscopy of urticaria pigmentosa with and without darier's sign in skin of colour p. 577
Balakrishnan Nirmal, Ananthu Subbaraman Krishnaram, Yegu Muthu, Poongodi Rajagopal
Urticaria pigmentosa is the most common form of mastocytosis that often develops in infancy or early childhood. We report two male children– first, a 7-month-old child with a history of asymptomatic multiple dark colored skin lesions macules with wheals on gentle rubbing (Darier's sign) and second, a 2-year-old child with similar clinical presentation without Darier's sign. Dermoscopy showed dark brown lines in a reticulate pattern which is an exaggeration of the pigment network seen in the normal skin. The reticulate pigment network was darker and thicker in the child with positive Darier's sign. This is the first case report of dermoscopy of urticarial pigmentosa with and without Darier's sign reported in skin of colour.
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Epitope spreading phenomenon: A case report p. 580
Keerthana Krishnaswamy, Belliappa Pemmada Raju, Leena Raveendra
The concomitant occurrence of psoriasis vulgaris (PV) and bullous pemphigoid in a patient is rare. We report a 55-year-old male, with history of PV since 4 years, on irregular topical medication, who developed multiple fluid-filled lesions all over the body. A combination treatment with prednisolone, cyclosporine, and dapsone followed by methotrexate was proved suitable and effective.
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Penile edema and lichenoid plaques on scrotum: An unusual presentation of secondary syphilis p. 585
Prince Y Singh, Subramaniyan Radhakrishnan, Shekhar Neema, Anwita Sinha
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Dowling-Degos disease - A novel presentation of an uncommon disease p. 587
Prasenjeet Mohanty, Sonal Jain, Liza Mohapatra, Srikanta Acharya
Dowling-Degos Disease is a rare, pigmentary disorder with variable presentations. The most common among them are hyperpigmented macules and reticulate pigmentary anomaly of flexures. Many other phenotypic variations of Dowling-Degos disease have been reported in literature. We present here a case of Dowling-Degos disease with comedo-like lesions and pits without typical flexural hyperpigmented macules.
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Linear alopecic patches in a child: An unusual presentation of trichotillomania p. 591
Aastha Gupta, Sinu Rose Mathachan, Pooja Arora, Purnima Malhotra
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A new trigger for aquagenic wrinkling: Isotretinoin p. 593
Habibullah Akta
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Fighter aircraft and ejection: Report of a rare, unique occupational skin hazard p. 594
Sandeep Arora, Subramaniyan Radhakrishnan, Vipin Sharma, Nikhil Moorchung
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Detachable magnifier for electrosurgical procedures p. 596
Feroze Kaliyadan, Karalikkattil T Ashique, Kaberi Feroze
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SkIndia Quiz 53: A dusky red plaque with satellite lesions p. 598
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit, Ajit B Janagond
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Selection of control, randomization, blinding, and allocation concealment p. 601
Amrita Sil, Piyush Kumar, Rajesh Kumar, Nilay Kanti Das
Clinical trials looking at which treatment is better must have certain checks in place. Appropriate “control” selection while comparing the investigating agent to the “control group is essential to rule out selection bias. Randomization is another step to minimize variability or “confounders.” By randomization, research participants have an equal chance of being selected into any treatment group of the study, generating comparable intervention groups, thereby distributing the confounders. A trial can be “open labeled” or “blinded.” By the process of blinding, we make the participant and/or assessing physician unaware of the treatment he/she is going to receive. Thus, the element of bias which can creep in owing to personal preference or subjective component to the assessment of outcome can be eliminated. Concealment of allocation is done as the participant enters the trial. Concealment secures randomization and prevents “selection bias”.
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Unilateral blaschkoid lichen planus p. 606
Shrikant Kumavat
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The boy with thick fingers p. 608
Rajsmita Bhattacharjee, Adithya Nagendran, Vinay Keshavamurthy
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Dermatosis Neglecta - Report of a Case with Verrucous Plaque in a Child p. 609
Konakanchi Venkatachalam, P Sunandini Anila, Satti S A Bindu
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Dermoscopy of linear basaloid follicular hamartoma p. 610
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit, Ajit B Janagond
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Dermoscopy of keratosis pilaris p. 613
Sidharth Sonthalia, Jushya Bhatia, Mary Thomas
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Dermoscopy of lichen aureus p. 615
Ishmeet Kaur, Sundeep Chowdhry, Paschal D'Souza
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