Dermatology

Update on management of polycystic ovarian syndrome for dermatologists Shalini Gainder, Bharti Sharma Indian Dermatology Online Journal 2019 10(2):97-105 Polycystic ovarian syndrome (PCOS) is the commonest endocrine disorder in women having wide range of clinical manifestation. These women may present with reproductive, dermatological, metabolic, psychological, or neoplastic implications from adolescence to menopause. The common dermatological manifestations include hirsutism, acne, alopecia, or acanthosis nigricans. Women presenting with these dermatological manifestations must be evaluated for PCOS. A multidisciplinary team approach involving a reproductive endocrinologist, dermatologist, psychologist/psychiatrist, dietician, and sometimes a bariatric surgeon should be undertaken for long-term management of these patients. Unless metabolic and underlying endocrinal disturbances arecorrected and simultaneous life-style modification is adopted, cosmetic treatment would give only temporary relief.

Recent laboratory advances in diagnostics and monitoring response to treatment in leprosy Utpal Sengupta Indian Dermatology Online Journal 2019 10(2):106-114 The present review briefly summarizes the highlights of the recent advances in Mycobacterium leprae-specific tests for early diagnosis of leprosy. In addition to establishing the diagnosis of clinical cases of leprosy, these tests have also been used to detect subclinical infections in endemic population. Several attempts have been made from 1980 onward for standardization of specific diagnostic assays for early detection of leprosy. Brief account about the development and use of these assays has been described in this review article.

Dietary protein deficit and deregulated autophagy: A new Clinico-diagnostic perspective in pathogenesis of early aging, skin, and hair disorders Suruchi Garg, Ankita Sangwan Indian Dermatology Online Journal 2019 10(2):115-124 Background: Diet has an important role to play in the well-being of human body. Aims: The study intends to establish the “hypothesis of conscious, selective, and self-destruction i.e., deregulated autophagy of skin and hair in low dietary protein scenario” by determining the facial profile, clinical presentation, and histopathological correlation of deficient protein intake and missing of meals in a tertiary care aesthetic skin institute. Methods: A total of 98 patients of skin- and hair-related complaints were enrolled in the study and a histopathological correlation was established by skin and scalp biopsies in high and low protein groups. Results: A significant number of subjects (68.4%) were taking less than half of the recommended daily allowance of proteins and faced problems like hair fall, acne, pigmentation, vitiligo, hirsutism, melasma, and premature aging. Subjects missing breakfast were found to have hypothyroidism, diffuse hairfall, autoimmune disorders like vitiligo, lichen planus, and alopecia areata. Histopathological images from submental area showed loose and fragmented collagen in high carbohydrate group in comparison to high protein group where thick, uniformly stained collagen bundles were found in dermis. Histopathology of scalp tissue showed chronic perifollicular inflammatory infiltrate and fibrosis in high carbohydrate group which was absent in histopathology specimen of high protein group. Patients taking early and nutrient-rich breakfast had higher mean protein intakes and less severe skin and hair problems suggesting a role of circadian rhythm as well. Conclusion: Dietary protein adequacy and early breakfast have significant role in preventing self-destruction or deregulated autophagy in trichology and cosmetic dermatology and may prevent various autoimmune, inflammatory, and metabolic diseases.

Oral antifungal therapy: Emerging culprits of cutaneous adverse drug reactions Raju G Chaudhary, Santoshdev P Rathod, Ashish Jagati, Dhara Zankat, Arwinder K Brar, Bansri Mahadevia Indian Dermatology Online Journal 2019 10(2):125-130 Introduction: Antifungals are one of the most widely used drugs in dermatology practice for dermatophytosis. Oral antifungal therapy against superficial dermatophytosis is generally associated with a low incidence of adverse events in an immunocompetent population. However, lately, cutaneous adverse drugs reactions (CADRs) have been reported with varying incidence rates in the patients on oral antifungal therapy with many uncommon morphological patterns. The present, observational study was conducted over a period of 4 months to report the cases which presented with antifungal therapy-associated CADRs. Materials and Methods: It was an observational, prospective study carried out at a tertiary care center in Western India over a period of 4 months. All patients diagnosed with superficial dermatophytic infections (clinically and fungal hyphae seen on 10% potassium hydroxide mount) started on oral antifungal therapy, presenting with cutaneous manifestation other than the primary dermatophytosis were included. The incidence of CADRs due to oral antifungal agents and the percentage of each clinical type of the CADR observed was calculated. Results: The incidence of CADRs due to antifungal drugs was 8.3 per 10,000 patients. In total, 35 cases were reported out of 4,208 cases of dermatophytosis. Terbinafine was the most common causative drug, accounting for nearly 83% of cases, followed by itraconazole for 14% cases, and griseofulvin for 2.8% of cases. Conclusion: The role of systemic antifungals must not be overlooked in any patient with a CADR and should be reported as a trend indicator.

Association of Vitamin D receptor gene polymorphisms and serum 25-Hydroxy Vitamin D levels in vitiligo – A case-control study Iffat Hassan, Yasmeen J bhat, Sabhiya Majid, Peerzada Sajad, Farhan Rasool, Rawoof A Malik, Inam Ul Haq Indian Dermatology Online Journal 2019 10(2):131-138 Background: Vitamin D has stimulatory and protective effects on melanocytes and acts through its nuclear vitamin D receptor (VDR) on target cells. Various single-nucleotide polymorphisms (SNPs) in VDR genes have been described. Aims: The aim was to study and compare the association of SNP of BsmI/Apa-I/TaqI/FokI/Cdx2 in VDR gene as well as the plasma vitamin D levels in vitiligo patients and healthy controls. Methods: This was a case-control study, in which 100 patients of vitiligo and an equal number of healthy individuals were studied. The VDR polymorphisms of Bsm I, Apa-I, TaqI, fok I, and cdx2 were investigated, after extraction of genomic DNA by rapid capillary polymerase chain reaction with melting curve analysis, and 25 hydroxy vitamin D levels were measured in cases and controls. Results: The frequency of genotypes (SNP FokI and cdx2) was higher in the patient group versus controls (P = 0.002). The genotype frequency (TaqI and Apa-I) was higher in the patients than the controls for the Tt genotype, but not significantly higher (48% vs. 39%, P= 0.1431). The difference between the groups in frequency of the genotype Aa(TaqI and Apa-I) was statistically significant (P = 0.0001 and P= 0.033). Statistically significant difference was also observed in Apa-I-evaluated alleles in cases when compared to controls (P = 0.0001). There was no significant difference in serum vitamin D levels between various genotypes among cases and controls. Out of 100 cases, 10 were found to have vitamin D levels of >30 ng/ml, 15 had levels between 20 and 30 ng/ml, 52 had ≤20 ng/ml, and 23 ≤ 10 ng/ml, respectively. Limitations: Since the skin biopsies were not taken from the lesions of vitiligo, the correlation of serum levels with tissue levels of VDR gene was not possible and the role of vitamin D supplementation was not evaluated. Conclusion: The single nucleotide gene polymorphisms of various VDR genes as found in the cases might lead to vitamin D deficiency, due to VDR dysfunction, which in turn could increase the susceptibility to develop vitiligo.

Awareness of cosmetic dermatology procedures among health workers in a Tertiary Care Hospital Deeptara P Thapa Indian Dermatology Online Journal 2019 10(2):139-143 Introduction: Cosmetic dermatology is a branch of dermatology which deals with the enhancement of beauty. There is a rise in cosmetic dermatological procedures throughout the world, but its awareness is limited not only in the general population but also among the health workers. Materials and Methods: We conducted a cross-sectional questionnaire-based study to know the knowledge and awareness of cosmetic dermatological procedures among health workers in a hospital setting. Results: There were a total of 155 respondents. The maximum number of respondents belonged to age group of 20–30 years (65.2%). Female respondents were 66% and males were 34%. Of the total respondents, 39% were medical students, 31% doctors, 23% nurses, 6% OPD assistants, and 1% ward maids. Hinduism was practiced by 91% of the respondents. About 84.5% of subjects were aware of cosmetic dermatological procedures. Regarding the source of information, 34.2% implicated textbooks. According to 53.5% participants, cosmetic dermatological procedures are done by a dermatologist. Around 59.4% responded that they were aware of many procedures such as botox injections, laser hair removal, hair transplant, and chemical peeling; 51% were aware of risks associated with procedures, such as allergy, burns, and pigmentation; 44.5% rated the facility as good; 31% believed that outcome of the procedures is different in Nepal as compared to a foreign countries. About 23.9% thought public disposition will change if they underwent the procedures. Around 11.6% thought this shall negatively affect them; however, 53.5% believed it would be socially acceptable. About 78.1% thought that these procedures are done only in cities with 62.6% believing it is commonly done by high-class economic status people. About 73.5% respondents believed that this was adopted by literate people; 7.1% were concerned about taboos against cosmetic dermatosurgical procedures; 84.5% agreed that there should be awareness program on these procedures. Conclusion: We found lack of awareness, knowledge, attitudes, and disposition about cosmetic dermatosurgical procedures among health workers. Further community-based population studies and awareness programmes should be carried out regarding this aspect.

An observational study to describe the clinical pattern of dermatological emergencies from emergency department and intensive care unit: Our experience from a tertiary care hospital in Northern India Debdeep Mitra, Ajay Chopra, Neerja Saraswat, Reetu Agarwal, Sushil Kumar Indian Dermatology Online Journal 2019 10(2):144-148 Background: A large number of skin diseases have the potential to culminate into potentially fatal “acute skin failure.” The concept of dermatological intensive care unit (ICU) has largely evolved as a result of increased number of emergencies encountered by dermatologists these days. Dermatological emergencies comprise 8–20% of cases presenting to the emergency department. A wide variety of these conditions require a collective effort by intensivists, surgeons, physicians, and nursing staff in association with the treating dermatologist to reduce the associated mortality and morbidity. Dermatology ICU along with state-of-the-art nursing care is required to manage these cases, which result in acute skin failure. Materials and Methods: A prospective study conducted in a tertiary care center with a round the clock emergency department and a state-of-the-art dermatology ICU over a period of 12 months. Patients requiring primary dermatological consultation in the emergency department and patients admitted in the dermatology intensive care unit were evaluated, and their clinical variables were statistically analyzed. Results: In total, 327 cases were seen in the emergency department, out of which 54 (16.5%) cases were admitted in dermatology ICU, 239 (73.1%) were treated as outpatient cases, and 34 (10.4%) were managed as inpatients in other wards of the hospital. The most common condition in out-patient cases was acute urticaria and angioedema in 71 (29.7%), while vesiculobullous disorders in 16 (29.6%) patients was the most common condition requiring admission in dermatology ICU. Conclusions: At present, only few studies are available in the literature on the spectrum of dermatological disorders reporting to emergency department, and further requiring intensive care under ICU setting. This prospective study highlights the varied patterns of dermatosis reporting to emergency outpatient department and those managed in the ICU.

Idiopathic localized involutional lipoatrophy: A retrospective study of 12 cases Reena K Sharma, Mudita Gupta, Lalita Negi Indian Dermatology Online Journal 2019 10(2):149-152 Background: Idiopathic localized involutional lipoatrophy (ILIL) is focal loss of subcutaneous tissue without any clinical or histopathological inflammation with spontaneous regression. Objective: To retrospectively study clinical features and evolution of lesions in patients diagnosed with idiopathic localized lipoatrophy presenting to the department of dermatology of two district hospitals of Himachal Pradesh. Materials and Methods: A retrospective study of clinical patterns and evolution of ILIL was done in patients presenting with this condition in two district hospitals in the past 4 years (October 2013–September 2017). All clinically suspected and histopathologically confirmed cases of idiopathic localized lipoatrophy were included in the study. All cases with history of antecedent injections, vaccination, or medications before the development of lesion and inflammatory lipoatrophy on histopathology were excluded. Results: We found a total of 12 patients with ILIL. About 66% were children (8/12), 3 (25%) young females, and 1 (8%) young adult male. The most common site involved was buttock in 9 (75%) cases followed by a single case each (8%) with lesion on arm, face, and lower back. Two children and one adult were having bilateral involvement (25%), whereas the remaining had unilateral lesions. Lipoatrophy in 8 (66%) patients decreased spontaneously (with placebo) within 4–12 weeks duration whereas 4 required treatment. None required surgical or cosmetic interventions. Limitations: Small sample size and nonavailability of immunohistochemistry reports in all patients. Conclusion: ILIL is a rare form of lipoatrophy with specific loss of adipose tissue without any inflammatory changes. We concluded that ILIL is an underreported entity, probably due to its spontaneous resolution.

Study on assessment of quality of life and depression in patients of vitiligo RahulKrishna S Kota, Rita V Vora, Jagdish R Varma, Suresh K Kota, Trusha M Patel, Jaishree Ganjiwale Indian Dermatology Online Journal 2019 10(2):153-157 Context: Vitiligo is an autoimmune pigmentary disorder characterized by localized or generalized depigmentation of the skin. It is associated with significant stigma and has impact on patient's quality of life (QoL) and psychological wellbeing. Aims: To see the variance in QoL and level of depression in vitiligo patients with extent of vitiligo. Materials and Methods: Vitiligo patients aged ≥18 years attending OPD were included in the study. Impairment in QoL was assessed by administering DLQI (Dermatology Life Quality Index) and VIS22 (Vitiligo Impact Scale22). Depression was assessed by administering QIDSSR16 (Quick Inventory of Depressive Symptomatology). The Vitiligo Area Scoring Index (VASI) was calculated based on clinical examination. Results: One hundred and fifty patients enrolled. Most common age group was 18–30 years. Mean DLQI, VIS22, QIDSSR16 scores were 7.02, 16.37, 5.87, respectively. QoL was affected to some extent in 85.3% and 86.7% according to the DLQI and VIS22, respectively. Depression was seen in 44%. Coclusion: Young patients showed higher impairment in QoL and also higher levels of depression. It would be useful to offer psychiatric consult and counseling in addition to specific treatment.Context: Vitiligo is an autoimmune pigmentary disorder characterized by localized or generalized depigmentation of the skin. It is associated with significant stigma and has impact on patient's quality of life (QoL) and psychological wellbeing. Aims: To see the variance in QoL and level of depression in vitiligo patients with extent of vitiligo. Materials and Methods: Vitiligo patients aged ≥18 years attending OPD were included in the study. Impairment in QoL was assessed by administering DLQI (Dermatology Life Quality Index) and VIS22 (Vitiligo Impact Scale22). Depression was assessed by administering QIDSSR16 (Quick Inventory of Depressive Symptomatology). The Vitiligo Area Scoring Index (VASI) was calculated based on clinical examination. Results: One hundred and fifty patients enrolled. Most common age group was 18–30 years. Mean DLQI, VIS22, QIDSSR16 scores were 7.02, 16.37, 5.87, respectively. QoL was affected to some extent in 85.3% and 86.7% according to the DLQI and VIS22, respectively. Depression was seen in 44%. Conclusion: Young patients showed higher impairment in QoL and also higher levels of depression. It would be useful to offer psychiatric consult and counseling in addition to specific treatment.

Barber Say Syndrome (A new case report) Mehrdad Rezaei, Susan Zamani, Hourvash Haghighinejad Indian Dermatology Online Journal 2019 10(2):158-161 Barber Say syndrome (BSS) is a rare ectodermal dysplasia with neonatal onset characterized by congenital generalized hypertrichosis, atrophic skin, ectropion and macrostomia. A literature review showed less than 20 previously reported cases of Barber Say syndrome. This presentation reports a one day old female with syndrome face, low hairline, coarse face, macrostomia, thin upper lip, bilateral ectropion and hypertelorism, hypertrichosis, senile skin appearance, hypoplastic nipples and one area of mild skin atrophy. These findings are consistent with BSS.