• Users Online: 702
  • Print this page
  • Email this page

  Table of Contents  
Year : 2014  |  Volume : 5  |  Issue : 4  |  Page : 413-415  

The case for case reports

Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication10-Oct-2014

Correspondence Address:
M Ramam
Room 4070, Teaching Block, Fourth Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5178.142480

Rights and Permissions

How to cite this article:
Rao A, Ramam M. The case for case reports . Indian Dermatol Online J 2014;5:413-5

How to cite this URL:
Rao A, Ramam M. The case for case reports . Indian Dermatol Online J [serial online] 2014 [cited 2021 Mar 8];5:413-5. Available from: https://www.idoj.in/text.asp?2014/5/4/413/142480

In the real world, scientific content is not the only criterion on which reports are judged. People (and editors) place different values on different kinds of scientific reports. Reports from authors of industrialized nations are likely to be given more weightage than those coming from developing nations. [1],[2] Articles from well-established authors, eminent personalities or those who have made significant contribution to a field stand a greater chance of acceptance than those from new comers. Grammatical and spelling errors in an article lower its chance of acceptance. Articles on drugs which are funded by companies are thought to be less reliable. In the olden days, when there was no online submission, quality of paper and typing of the manuscript also mattered in its acceptance. In general, the use of such criteria to evaluate a paper is discouraged and we are urged to focus on the content of the article.

However, there is one kind of discrimination that appears to be officially sanctioned. Evidence-based medicine is concerned with finding the best evidence for making clinical decisions. Hence, a hierarchy of evidence is proposed with meta-analysis on top which serves as the final evaluation of therapies or tests, especially when their clinical value is not immediately clear-cut. This is followed by randomized controlled double blind studies, cohort studies and case control studies. Case reports and case series constitute the bottom layers of the pyramid and their importance is often questioned. The general perception is that they contain anecdotal reports which cannot be extrapolated to the general population and more often than not, new ideas from case reports are not sustained on further research. They are thought to do more harm than good by highlighting the bizarre manifestations. [3] There is also the perception that case reports and series are easier to write and so are less worthy of respect.

Moreover, the goal of journals to maintain a high impact factor is a major deterrent to the publication of case reports. The impact factor is determined by how often articles from any given journal are cited in other medical publications. Meta-analyses are cited most often and case reports usually receive the least number of citations. [4] This observation makes editors hesitant to increase the number of case reports that they publish.

Case reports and case series, however, have aims that are equally important in the progress of medical science and education. [5],[6]

One of the major hallmarks of case reports and case series is their ability to bring out novel ideas. [7] They often serve as the first line of evidence for new therapies. Many of the breakthrough drug discoveries for their use in dermatological conditions have been based on case reports and case series. These include propranolol for infantile hemangiomas, [8] tranexamic acid in melasma, [9] thalidomide in erythema nodosum leprosum, [10] minoxidil for androgenetic alopecia, [11] rituximab in pemphigus vulgaris, [12] dapsone in Behcet's disease [13] where the first four were chance observations.

Many of the novel treatment modalities like pulse therapy in pemphigus, [14] oral mini pulse for vitiligo, [15] two-step regimen for actinomycotic mycetoma, [16] weekly azathioprine pulse for parthenium dermatitis [17] emanated as case reports and case series.

Case reports and case series are often the first and sometimes a major source for detecting rare adverse events. Only case-control studies, or very large cohort studies are able to quantify the occurrence of these side effects. Nicorandil causing perianal ulceration, [18] hydroquinone causing exogenous ochronosis, [19] cyclophosphamide causing neutrophilic eccrine hidradenitis, [20] anti tumor necrosis factor-α medications causing paradoxical exacerbation of psoriasis [21] are examples of rare adverse effects of drugs used in dermatological conditions which have been highlighted by case series and case reports.

Recognition and description of new diseases, clinical recognition of rare diseases and new or rare presentations of known diseases is another aim of case reports and case series. The serendipitous finding of palmar freckles/melanotic macules in type 1 neurofibromatosis- Yesudian et al.' sign, [22] the finding of cerebriform tongue as a clinical sign in pemphigus vegetans, [23] the characteristic diagnostic cutaneous features of pentazocine-induced ulcers, [24] facial acanthosis nigricans associated with obesity, [25] contact depigmentation occurring from free para-tertiary-butylphenol in bindi adhesive, [26] the pattern of frictional sweat dermatitis, [27],[28] dermatitis on the knee following knee replacement [29] are all examples of rare but important conditions highlighted by case reports and case series.

The initial report of a clinical finding or syndrome often leads others to recognize the pattern and is followed by a number of other reports. E.g., post kala-azar dermal leishmaniasis, [30] dental amalgam and oral lichen planus [31] and sporotrichoid spread of cutaneous tuberculosis. [32] A case report of an unusual presentation of a disease or of a rare disease encourages physicians of recall of cases that they may have seen and missed. Such a recall would also make physicians more vigilant in future when they see a similar presentation.

Case reports and series also have teaching value as they present a detailed description of clinical cases containing important details about signs, symptoms and other patient characteristics, and report the therapeutic procedures used, as well as the outcome of the case. A case report often serves as the beginning of ones writing career and provides an excellent opportunity for private practitioners to contribute to academic activity. More so in a country like ours where dermatologists are predominantly in private practice. This would enable a large collection of variety of cases.

In addition, in certain situations, a case report is the basis for the elaboration of larger studies. Novel observations in case reports can be followed up by subsequent clinical trials and could therefore be considered to be important hypothesis-generating reports. [33] E.g., propranolol for infantile hemangiomas, [8] minoxidil for androgenetic alopecia. [11]

Case reports are also important as they permit the accumulation of cases which create the conditions for the early perception of a new or resurgent epidemic. E.g., air borne contact dermatitis due to parthenium. [34]

Further, as there are numerous rare diseases in dermatology, it becomes difficult to recruit sufficient number of cases to perform any trial for testing efficacy of drugs. In such situations, the information from case series becomes valuable.

Another benefit of these studies is that they can be carried out by solo practitioners and do not require an institutional set up. Randomized controlled trials, on the other hand, are difficult to undertake and often there is lack of commercial interest in testing older medications or those for orphan diseases.

One of the arguments against case reports and series is that they have lesser specificity for medical decision making. [5] However, Chalmers drew attention to a review of the number of side effect reports that were ultimately sustained: After further investigation, 35 of 47 anecdotal reports were qualified as "clearly correct." [35],[36]

Moreover, a case report backed by good quality photographs does not hide or distort facts, something which other studies cannot claim.

With all these advantages to its credit, it is now a question of debate as to whether case reports and case series deserve to be at the bottom of hierarchy of evidence. There is a clear misrepresentation of these and their value is underrated.

Case reports and series have their own share of drawbacks. [37] Case reports and case series base their conclusions on a small number of cases. The reported case may not be representative of the entire spectrum of disease. There is no control group incorporated for comparison. Case reports and series do not have a methodology capable of validating a causal relationship and the diagnostic methodology is not standardized. Furthermore, there is a marked publication bias associated with case reports: Only impressive or interesting situations are likely to be reported. In one survey, the number of published case reports and case series reporting successes was 90% versus 10% reporting failures. [33]

To conclude, case reports and series are a necessary element of medical publishing. Their major role is in reporting novelty though they have the drawback of an excessive emphasis on the unusual.

   References Top

Patel V, Sumathipala A. International representation in psychiatric literature: Survey of six leading journals. Br J Psychiatry 2001;178:406-9.  Back to cited text no. 1
Mendis S, Yach D, Bengoa R, Narvaez D, Zhang X. Research gap in cardiovascular disease in developing countries. Lancet 2003;361:2246-7.  Back to cited text no. 2
Hoffman JR. Rethinking case reports. West J Med 1999;170:253-4.  Back to cited text no. 3
Patsopoulos NA, Analatos AA, Ioannidis JP. Relative citation impact of various study designs in the health sciences. JAMA 2005;293:2362-6.  Back to cited text no. 4
Vandenbroucke JP. Case reports in an evidence-based world. J R Soc Med 1999;92:159-63.  Back to cited text no. 5
Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med 2001;134:330-4.  Back to cited text no. 6
Albrecht J, Werth VP, Bigby M. The role of case reports in evidence-based practice, with suggestions for improving their reporting. J Am Acad Dermatol 2009;60:412-8.  Back to cited text no. 7
Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358:2649-51.  Back to cited text no. 8
Sadako N. Treatment of melasma with tranexamic acid. Clin Rep 1979;13:3129-31.  Back to cited text no. 9
Sheskin J. Thalidomide in the treatment of lepra reactions. Clin Pharmacol Ther 1965;6:303-6.  Back to cited text no. 10
Yesudian P. Serendipity in trichology. Int J Trichology 2011;3:1-2.  Back to cited text no. 11
Ahmed AR, Spigelman Z, Cavacini LA, Posner MR. Treatment of pemphigus vulgaris with rituximab and intravenous immune globulin. N Engl J Med 2006;355:1772-9.  Back to cited text no. 12
Sharquie KE. Suppression of Behçet's disease with dapsone. Br J Dermatol 1984;110:493-4.  Back to cited text no. 13
Pasricha JS, Gupta R. Pulse therapy with dexamethasone-cyclophosphamide in pemphigus. Indian J Dermatol Venereol Leprol 1984;50:199-203.  Back to cited text no. 14
Pasricha JS, Khaitan BK. Oral mini-pulse therapy with betamethasone in vitiligo patients having extensive or fast-spreading disease. Int J Dermatol 1993;32:753-7.  Back to cited text no. 15
Ramam M, Garg T, D'Souza P, Verma KK, Khaitan BK, Singh MK, et al. A two-step schedule for the treatment of actinomycotic mycetomas. Acta Derm Venereol 2000;80:378-80.  Back to cited text no. 16
Verma KK, Bansal A, Sethuraman G. Parthenium dermatitis treated with azathioprine weekly pulse doses. Indian J Dermatol Venereol Leprol 2006;72:24-7.  Back to cited text no. 17
[PUBMED]  Medknow Journal  
Watson A, Al-Ozairi O, Fraser A, Loudon M, O'Kelly T. Nicorandil associated anal ulceration. Lancet 2002;360:546-7.  Back to cited text no. 18
Findlay GH, Morrison JG, Simson IW. Exogenous ochronosis and pigmented colloid milium from hydroquinone bleaching creams. Br J Dermatol 1975;93:613-22.  Back to cited text no. 19
Lienesch DW, Mutasim DF, Singh RR. Neutrophilic eccrine hidradenitis mimicking cutaneous vasculitis in a lupus patient: A complication of cyclophosphamide. Lupus 2003;12:707-9.  Back to cited text no. 20
Collamer AN, Guerrero KT, Henning JS, Battafarano DF. Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: A literature review and potential mechanisms of action. Arthritis Rheum 2008;59:996-1001.  Back to cited text no. 21
Yesudian P, Premalatha S, Thambiah AS. Palmar melanotic macules. A sign of neurofibromatosis. Int J Dermatol 1984;23:468-71.  Back to cited text no. 22
Premalatha S, Jayakumar S, Yesudian P, Thambiah AS. Cerebriform tongue-a clinical sign in pemphigus vegetans. Br J Dermatol 1981;104:587-91.  Back to cited text no. 23
Prasad HR, Khaitan BK, Ramam M, Sharma VK, Pandhi RK, Agarwal S, et al. Diagnostic clinical features of pentazocine-induced ulcers. Int J Dermatol 2005;44:910-5.  Back to cited text no. 24
Veysey E, Ratnavel R. Facial acanthosis nigricans associated with obesity. Clin Exp Dermatol 2005;30:437-9.  Back to cited text no. 25
Bajaj AK, Gupta SC, Chatterjee AK. Contact depigmentation from free para-tertiary-butylphenol in bindi adhesive. Contact Dermatitis 1990;22:99-102.  Back to cited text no. 26
Mehta RD, Bumb RA. Sweat dermatitis. Int J Dermatol 2000;39:872.  Back to cited text no. 27
Ramam M, Khaitan BK, Singh MK, Gupta SD. Frictional sweat dermatitis. Contact Dermatitis 1998;38:49.  Back to cited text no. 28
Verma SB, Mody B, Gawkrodger DJ. Dermatitis on the knee following knee replacement: A minority of cases show contact allergy to chromate, cobalt or nickel but a causal association is unproven. Contact Dermatitis 2006;54:228-9.  Back to cited text no. 29
Brahmachari UN. A new form of cutaneous leishmaniasis-Dermal leishmanoid. Ind Med Gaz 1927;57:125-7.  Back to cited text no. 30
Nakayama H, Oshiro A, Sato S, Nakano N. 2 cases of lichen planus apparently caused by allergy to dental metals. Jibiinkoka 1972;44:239-47.  Back to cited text no. 31
Ramesh V. Sporotrichoid cutaneous tuberculosis. Clin Exp Dermatol 2007;32:680-2.  Back to cited text no. 32
Albrecht J, Meves A, Bigby M. Case reports and case series from Lancet had significant impact on medical literature. J Clin Epidemiol 2005;58:1227-32.  Back to cited text no. 33
Lonkar A, Jog MK. Dermatitis caused by plant Parthenium hysterophorus: A case report. Indian J Dermatol Venereol Leprol 1968;34:194-6.  Back to cited text no. 34
Chalmers I. Evaluating the effects of care during pregnancy and childbirth. In: Chalmers I, Enkin M, Keirse MJ, editors. Effective Care in Pregnancy and Childbirth. New York: Oxford University Press; 1989. p. 3-38.  Back to cited text no. 35
Venning GR. Validity of anecdotal reports of suspected adverse drug reactions: The problem of false alarms. Br Med J (Clin Res Ed) 1982;284:249-52.  Back to cited text no. 36
Parente RC, de Oliveira M, Celeste RK. Case reports and case series in the era of evidence-based medicine. Bras J Video Sur 2010;2:63-6.  Back to cited text no. 37


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article

 Article Access Statistics
    PDF Downloaded305    
    Comments [Add]    

Recommend this journal