Dermatology

Antifungal drug susceptibility testing of dermatophytes: Laboratory findings to clinical implications Sunil Dogra, Dipika Shaw, Shivaprakash M Rudramurthy Indian Dermatology Online Journal 2019 10(3):225-233

What is new in narrow-band ultraviolet-B therapy for vitiligo? Urmi Khanna, Sujay Khandpur Indian Dermatology Online Journal 2019 10(3):234-243 Vitiligo is an acquired disorder of skin pigmentation that produces significant psychological impact especially in those with skin of color. Narrow-band ultraviolet B (NB-UVB) therapy, which was first used in vitiligo in 1997 by Westerhof and Nieuweboer-Krobotova, has emerged as one of the safest and most effective therapy for this dermatosis. The light source used for NB-UVB phototherapy is the TL-01 lamp, and the most common model of the NB-UVB phototherapy device is the upright in-office booth or chamber which has 24–48 such lamps. In recent years, there have been several advances in the understanding of the mechanism of action of NB-UVB and the use of combination treatments, many of which increase the efficacy of NB-UVB. In 2017, the Vitiligo Working Group made vital recommendations on the dosage, frequency, and safety of NB-UVB in vitiligo. Furthermore, home phototherapy devices are gaining popularity as they lead to an improved patient compliance. There is still need for large multicenter randomized controlled trials to assess benefits of home phototherapy in vitiligo and studies investigating additional benefits of phototherapy following surgical therapy.

Newer treatment modalities in epidermolysis bullosa Leena Bruckner-Tuderman Indian Dermatology Online Journal 2019 10(3):244-250 The term epidermolysis bullosa (EB) refers to a group of hereditary skin blistering diseases. The group is clinically and genetically heterogeneous, but all EB forms are associated with mechanically induced skin blistering and fragility. The causative gene mutations of most EB types are known. The current international consensus classification contains four main types: EB simplex (EBS), junctional EB (JEB), dystrophic EB (DEB), and Kindler syndrome (KS). The classification is based on the morphological level of blister formation. In EBS, the split is intra-epidermal, in JEB along the basement membrane and in DEB below the basement membrane. In Kindler syndrome, the dermal-epidermal junction is disorganized, and blisters can occur on all three levels. Each major EB type has further subtypes which may differ in terms of their genetic, biological or clinical characteristics. Traditionally, EB treatments have been symptomatic, but increasing understanding of disease etio-pathogenesis is facilitating development of novel evidence-based therapy approaches. First gene- and cell-based therapies are being tested at preclinical level and in clinical trials. New knowledge on secondary disease mechanisms has led to development and clinical testing of urgently needed symptom-relief therapies using small molecules and biologicals.

Clinical profile of cutaneous adverse effects of epidermal growth factor receptor inhibitors: A prospective observational study of 76 cases Neerja Saraswat, Aradhana Sood, Dharmesh Kumar, Rajesh Verma, Kumar Sushil Indian Dermatology Online Journal 2019 10(3):251-255 Background: Epidermal growth factor receptor (EGFR) inhibitors are an extensively utilized class of chemotherapeutic agents which form an integral component of treatment in solid organ malignancies such as non-small-cell lung carcinoma, pancreatic carcinoma, colorectal carcinoma, and head and neck carcinoma. It has two subclasses: epidermal growth factor inhibitors (erlotinib) and monoclonal antibody (cetuximab). A wide array of cutaneous adverse effects has been attributed to this class of drugs, such as papulopustular eruptions, paronychia, xerosis, and changes in hair and nails. Materials and Methods: A total of 76 cases of various malignancies on EGFR inhibitors who developed cutaneous side effects while on therapy and reported or referred to us by oncologists from January 2017 to January 2018 were included in the study. All the patients who were on other associated medications or radiotherapy were excluded. Result: In all, 45 (59.2%) were males and 31 (40.7%) were females. Non-small-cell lung carcinoma was the most common carcinoma in 32 (42.1%) patients, and cetuximab was the most common drug in 29 (38.1%) cases. Papulopustular eruptions were seen in 61 (80.2%) patients, xerosis in 31 (40.7%), mucositis in 6 (7.8%), hair growth problems in 4 (5.6%), and paronychia and pyogenic granuloma in 2 (2.6%) patients each. Conclusion: Although most of the skin toxicities associated with EGFR inhibitors can be managed conservatively, a critical analysis of the cases that are significantly affected due to these side effects is required in cohesion with the treating oncologist to improve the therapeutic compliance of the drug.

Mycetoma: A common yet unrecognized health burden in central India Gitesh U Sawatkar, Vaishali H Wankhade, Bhagyashree B Supekar, Rajesh Pratap Pratap, Dharitri M Bhat, Supriya S Tankhiwale Indian Dermatology Online Journal 2019 10(3):256-261 Context: Mycetoma is a chronic suppurative infective disorder of skin, subcutaneous tissue, fascia, and bones caused by the traumatic inoculation of either fungal (eumycotic) or bacterial (actinomycotic) organisms present in the soil. Triad of tumefaction, discharging sinuses, and grains characterizes the disease. Aims: This study was undertaken to study the clinical spectrum and treatment response of mycetoma in central India. Settings and Design: It was a retrospective study of clinical and/or biopsy-proven and treated cases of mycetoma from November 2015 to October 2016. Subjects and Methods: Medical records of diagnosed and treated mycetoma patients were enrolled retrospectively during November 2015 and October 2016. Case records of patients were evaluated with respect to demographic, clinical, microbiological details, bone involvement, and treatment. Type of therapies and outcome, wherever available, were also assessed. Statistical Analysis: Statistical analysis was done using proportion, mean, and percentages. Results: Eleven cases (male = 8) were seen during the study period (seven actinomycetoma and four eumycetoma). Foot and lower extremity was the most common site (9/11), whereas upper extremity and forehead were involved in one case each. On culture, the organisms isolated were Phialophora and Fusarium. Modified Welsch regimen was started in six of seven patients with actinomycetoma, whereas one was started on sulfamethoxazole–trimethoprim and a combination of amoxicillin and clavulanic acid therapy. All four cases of eumycetoma were treated with itraconazole. On follow-up, six cases of actinomycetoma cases showed significant improvement. Two cases of eumycetoma showed mild to moderate improvement and one case required surgical intervention. One case each of actinomycetoma and eumycetoma were lost to follow-up. Conclusion: Mycetoma has been recognized as a neglected tropical disease by the World Health Organization, recently. There are very few case reports from the central part of India. Prominent case detection in our study emphasizes the need of larger studies to know the extent of disease in this part of India.

The menace of superficial dermatophytosis on the quality of life of patients attending referral hospital in Eastern India: A cross-sectional observational study Nibedita Patro, Maitreyee Panda, Ajaya K Jena Indian Dermatology Online Journal 2019 10(3):262-266 Background: Superficial dermatophytic infections have come up with multiple challenges and comorbidities recently regarding its chronic and recurrent course. Aims: The present study aims at measuring the impact of the disease on the quality of life (QoL) of the patients. Methods: A cross-sectional observational study was conducted over 6 months. The patients attending the dermatology outpatient department were recruited after screening and were made to fill up the Dermatology Life Quality Index (DLQI) and 5D-pruritus scale questionnaires. The P value was calculated and data were compared using the Pearson's correlation coefficient. Results: A total of 294 patients were studied. The effect on QoL was estimated to be moderate [males, ≤10% body surface area (BSA) involvement, ≤6 months duration, low and medium socio-economic status (SES)] to very large (females, >10% BSA involvement, >6 months duration, high SES, and medium and high educational status) according to the DLQI scoring and correlated strongly with the disability scoring in 5D-pruritus scale (r = 0.802, P < 0.0001). Limitations: Small sample size of the study may not reflect the impact on general population, urging the need for multicenter studies. Conclusions: Although considered previously as a simple fungal infection, the present state of superficial dermatophytosis has emerged as a social, psychological, and economic burden on the society.

Transepidermal water loss in psoriasis: A case-control study Vrushali N Nikam, Rochelle C Monteiro, Sukumar Dandakeri, Ramesh M Bhat Indian Dermatology Online Journal 2019 10(3):267-271 Context: Psoriasis is a common papulosquamous disorder characterized by increased epidermal turnover resulting in excessive skin shedding and a compromised barrier function of the skin. Transepidermal water loss (TEWL) is an effective and non-invasive way to measure the barrier function in this condition. Aims: To measure the physiological changes in the skin barrier function in psoriasis by measuring the extent of TEWL. To study the differences in TEWL in pathologically involved and uninvolved skin in psoriasis. To compare the TEWL in skin lesions in psoriatic patients and site matched controls. Subjects and Methods: To determine the barrier quality of the stratum corneum, we performed TEWL measurements using the closed chamber evaporation method (VapoMeter Delfin Technologies, Kuopio, Finland). The ambient temperature ranged between 21°C and 24°C, with a mean relative humidity range of 39%–50%. In total, four sites were measured for all the 50 cases, two involved plaques on the body were selected for the study of lesional psoriatic skin, and the standard sites of ankle and elbow were measured irrespective of being involved or uninvolved with psoriatic skin. TEWL measurements in controls were site matched. Statistical testing was done using SPSS ver. 17. The interval scale data were tested for normality using Shapiro-Wilk test, and between groups testing was done using Mann-Whitney test. Results: The TEWL was higher among the cases in all the four measured areas compared to the controls, thus showing overall impaired skin barrier function in psoriatic skin. In addition, among the cases, the involved sites show higher TEWL in comparison to the uninvolved skin. This is highly suggestive that plaques of psoriasis have reduced water holding capacity. Conclusions: Psoriasis is a dermatosis with overall compromise of the skin barrier function exhibiting exponential TEWL in lesional skin, with increased TEWL over non-lesional skin as well. Thus, it may be concluded that TEWL is an effective, non-invasive and objective method in assessment of skin barrier function.

Association of acanthosis Nigricans and insulin resistance in indian children and youth – A HOMA2-IR based cross-sectional study TM Nithun, P. S. S Ranugha, Jayadev B Betkerur, Veeranna Shastry Indian Dermatology Online Journal 2019 10(3):272-278 Introduction: The American Diabetes Association includes acanthosis nigricans (AN) as an indicator of diabetes mellitus risk in overweight youth entering puberty. Some argue that AN is not an independent predictor of insulin resistance (IR), when body mass index (BMI) is controlled for. There is a paucity of studies on the association of AN and IR among children and young adults from India. Homeostatic model assessment-IR (HOMA2-IR), a computerized updated model, which is supposed to be superior to HOMA1-IR, has rarely been used for quantification of IR. Methods: Sixty cases (irrespective of BMI), aged 2–24 years with AN, and 30 age- and sex-matched normal weight controls were included. A thorough clinical examination and grading of AN was done. BMI, fasting glucose levels, and fasting insulin levels were measured for all. HOMA-IR calculator V.2.2.3 was used to calculate IR. Those with HOMA 2-IR >1.8 were considered insulin-resistant. Lifestyle modifications were advised for patients with IR. Results: The mean HOMA2-IR value in cases and controls was 2.422 and 1.322, respectively, which was statistically significant. Overweight and obese cases had 2.5 and 11.25 times higher risk of having IR, respectively, by logistic regression. The association of AN with IR was found to be statistically significant in normal weight cases when compared with controls (P = 0.045). Grade 4 of neck severity (P = 0.007), Grade 3 of neck texture (P = 0.001), and Grade 4 of axillary severity (P = 0.001) of AN were found to be significantly associated with IR. Limitations: The relatively small sample size may not reflect the accuracy of AN as a marker of IR. Conclusion: Acanthosis nigricans is associated with IR in both normal and obese. We propose that all children, adolescents, and youth with AN be screened for IR irrespective of BMI. Early identification and prompt lifestyle interventions may prevent or delay the onset of diabetes later.

Prescription and usage pattern of topical corticosteroids among out-patient attendees with dermatophyte infections and its analysis: A cross-sectional, survey-based study Raju G Chaudhary, Santoshdev P Rathod, Ashish Jagati, Kalgi Baxi, Akshay Ambasana, Disha Patel Indian Dermatology Online Journal 2019 10(3):279-283 Background: There is scarce scientific data on topical corticosteroids (TCS) prescription by non-dermatologists including registered medical practitioners, ayurvedic, homeopathic practitioners, and over-the-counter (OTC) use of TCS-containing creams. Objective: The main objective of this study is to analyze the prescription and usage pattern of topical steroids among out-patient attendees with dermatophyte infection. To study health-seeking behavior of patients with dermatophyte infections. Material and Methods: An open, cross-sectional, duration-based study of 3 months. Inclusion criteria: Patients with dermatophytosis having a history of topical steroid application; either prescribed or purchased OTC and used themselves. Exclusion criteria: Patients who were not willing to give informed consent. Patient's data like socio-demographic profile, duration, frequency, site of application, contents of the topical cream used, prescriber information, and patients' desire to continue the use of topical steroids were recorded. Results: Total of 18.40% (n = 503) patients were already using cream-containing TCS at the time of presentation to the tertiary dermatology care center. The study shows that almost half of the patients (48.90%) were using unprescribed TCS. Registered medical practitioners were the most common source of TCS creams prescription (59.92%) in the prescribed group, while 26.07% patients were prescribed TCS by dermatologists. Clobetasol propionate (47.91%), was most common steroid agent used. Conclusion: Patients are able to get “prescription-only” drugs as OTC products. Such OTC use of TCS puts patients at risk of steroid modified dermatophytosis and topical steroid damaged skin. Even dermatologists may be culprit in creating menace of steroid abuse.

Association of skin tag with metabolic syndrome and its components: A case–control study from Eastern India Tapaswini Tripathy, Bhabani S.T.P Singh, Bikash R Kar Indian Dermatology Online Journal 2019 10(3):284-287 Background: Skin tags are benign polyps, usually found in the natural folds of the skin. Some studies have found an association of skin tags with obesity, diabetes, hypertension, and atherogenic lipid profile. Metabolic syndrome refers to co-occurrence of these cardiovascular risk factors such as insulin resistance, obesity, dyslipidemia, and hypertension. Aims and Objectives: To find out any possible association of skin tags with metabolic syndrome and its components. Materials and Methods: A case–control study was conducted including 140 participants. Seventy patients with skin tags were considered cases, and 70 age- and sex-matched patients without skin tags were considered as controls. Various anthropometric and biochemical parameters were compared and analyzed between the two groups. Results: Univariate analysis revealed significantly higher waist circumference, high triglyceride, and low high-density lipoproteins (HDLs) in cases compared to controls. The prevalence of diabetes, hypertension, and metabolic syndrome was significantly higher in patients with skin tags, and risk of developing metabolic syndrome was 11.13 times higher in cases compared to controls (P < 0.05). Multivariate logistic regression analysis revealed high waist circumference and low serum HDL had significant association with skin tags. Conclusion: Risk of development of metabolic syndrome is significantly higher in patients with skin tags. Among the various components of metabolic syndrome, only high waist circumference and low serum HDLs are significantly associated with skin tags.

Alexandros Sfakianakis
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