Archana Singal

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.

Lichen scrofulosorum: A prospective study of 39 patients

Background  Lichen scrofulosorum is considered a rare form of cutaneous tuberculosis. Current information is based on case reports and case series with a small number of patients.

Topical permethrin and oral ivermectin in the management of scabies: A prospective, randomized, double blind, controlled study

BACKGROUND Scabies is a highly contagious and intensely pruritic parasitic infestation. It is a re-emerging infection in the new millennium especially with HIV pandemic and a significant health problem in developing countries. Various treatment modalities have been used since time immemorial but the search for an ideal scabicide is ongoing. AIMS In this study, we compared the therapeutic efficacy of single application of topical 5% permethrin with oral ivermectin (200 μg/kg/dose) in a single-dose and a two-dose regimen in patients with scabies. METHODS 120 clinically diagnosed cases of scabies (>5 years of age and/or >15 kg) were randomized into three treatment groups A, B, C of 40 patients each; receiving either topical 5% permethrin (group A) or oral ivermectin (200 μg/kg/dose) in a single dose (group B) or double dose regimen (group C) repeated at 2 weeks interval. Patients were followed up at 1, 2, and 4 weeks interval. At each visit, cure rate (>50% improvement in lesion count and pruritus and negative microscopy) was assessed and compared. RESULTS Cure rate in three treatment groups at the end of 4 weeks was 94.7% (A), 90% (B), 89.7% (C), and thus all three treatment modalities were equally efficacious. However, at 1 week follow up, group A patients reported better improvement in both lesion count and pruritus. CONCLUSIONS Both permethrin and ivermectin in both single and two dose regimen are equally efficacious and well tolerated in scabies. However, permethrin has a rapid onset of action.

Comparative efficacy of tacrolimus 0.1% ointment and clobetasol propionate 0.05% ointment in oral lichen planus: a randomized double-blind trial

Oral lichen planus (OLP) is a common disease of the oral mucosa with worldwide distribution and overall prevalence of 0.5–2.2%. Its etiology remains unclear, although the role of autoimmunity is supported by its association with other autoimmune diseases and the presence of auto‐cytotoxic T cell clones in the lesions. Although many options for treating symptomatic OLP are available, no therapy is curative. This trial compared treatments with topical tacrolimus 0.1% ointment and topical clobetasol propionate 0.05% ointment. Forty patients with histologically proven symptomatic OLP were divided into two groups of 20 to receive clobetasol propionate (0.05%) ointment or tacrolimus (0.1%) ointment for eight weeks. Follow‐up for all patients included three visits during the treatment course and one post‐treatment visit. At each visit, objective improvement in the lesions was assessed by two independent investigators. The primary outcome measure was defined as the percentage of patients attaining complete response at eight weeks. Secondary outcome measures were the percentages of patients attaining complete or partial response at 8 and 12 weeks. Patient‐observed improvement was evaluated at each visit. Demographic parameters and pretreatment disease characteristics were comparable between the groups. The mean net clinical score (NCS) declined progressively from baseline at each follow‐up visit in both groups. In the clobetasol group, the mean NCS declined from 8.00 ± 2.65 at baseline to 2.00 ± 1.49 at 12 weeks. In the tacrolimus group, the mean NCS declined from 7.78 ± 3.25 at baseline to 1.31 ± 1.06 at 12 weeks. At each visit, the decline in mean NCS from baseline was statistically significant (P < 0.05) in both groups. Complete response rates of 40% and 70%, respectively, were achieved in the clobetasol and tacrolimus groups (P = 0.057). The percentages of patients reporting “good” or “very good” treatment responses at week 8 were 74% in the clobetasol group and 100% in the tacrolimus group (P > 0.05). No severe adverse events were reported. Tacrolimus 0.1% ointment is an effective alternative to topical steroid and may be considered as a first‐line therapy in OLP.

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.

Cutaneous tuberculosis in children: the Indian perspective.

Cutaneous tuberculosis continues to be a significant medical problem even with the advent of highly effective antituberculous drugs. It constitutes about 1.5% of all extra pulmonary tuberculosis. The prevalence in children varies from 18 to 54% in India. There is no gender predilection and the infection occurs with increased frequency in 10-14 year age group. Intrafamilial source of TB has been observed very frequently. A concomitant TB lymphadenitis is most common while involvement of other systemic organs like lung, bone and abdomen has also been observed. Protective efficacy of BCG is debatable and not yet fully defined. Of all the clinical types, scrofuloderma (SFD) is the most commonly encountered variant followed by lupus vulgaris (LV) and tuberculosis verrucosa cutis (TBVC). Lichen scrofulosorum (LS) is generally found to be associated with systemic TB focus in about 72% of cases. The impact of HIV on childhood cutaneous TB seems to be minimal. Similar to adults, the diagnosis of cutaneous tuberculosis relies mainly on histopathology, culture on LJ medium or radiometric BACTEC 460 TB culture system and PCR. In addition Mantoux positivity and a positive therapeutic trial with anti-tubercular drugs may be a good pointer to tubercular infection. A thorough clinical evaluation and exhaustive investigations to pin-point associated systemic focus is advocated as the latter has an impact on the duration of treatment. Cutaneous TB in children is treated as per the recommendations of therapy for extrapulmonary TB.

Comparative Efficacy of Ketoconazole and Fluconazole in the Treatment of Pityriasis Versicolor : A One Year Follow-up Study

Pityriasis versicolor can be treated by a single or multiple dosage regime of ketoconazole as well as by fluconazole. The therapeutic efficacy of these two drugs has not been compared. One hundred and eighty patients with moderate to extensive pityriasis versicolor confirmed by KOH and Woods lamp examination were randomly assigned to one of the four oral antifungal regimes: Ketoconazole 400 mg single dose (Category I), Ketoconazole 200 mg daily for 10 days (Category II), Fluconazole 400 mg single dose (Category III) or Fluconazole 150 mg per week for 4 weeks (Category IV). Follow up was done at 2 and 4 weeks and then at 3, 6 and 12 months after the treatment in each group. KOH and Woods lamp examinations were repeated each time. After four weeks of treatment, clinical cure was observed in 66.6% (Category I), 73.3% (Category II), 80% (Category III) and 59.9% (Category IV) of patients. Mycological cure after four weeks of treatment was observed in 53.3% (Category I), 73.3% (Category II), 82.2% (Category III) and 64.4% (Category IV) of patients. After twelve months of follow‐up, maximum relapses were observed with Category I. No relapse was seen in Category III patients. The time period of relapse varied from three to ten months. In conclusion, single dose 400 mg oral fluconazole provided the best clinical as well as mycological cure rate with no relapse during twelve months of follow‐up.

Butenafine and superficial mycoses: current status

Background: Butenafine hydrochloride, a benzylamine derivative, exhibits potent fungicidal activity particularly against dermatophytes, aspergilli, dimorphic and dematiaceous fungi. Objective: To review pharmacokinetics, mechanism of actions and clinical efficacy of butenafine against various dermatophytic and other superficial fungal infections. Methods: Medline search was made using keyword butenafine. All English language articles were considered for this review. For inclusion in clinical efficacy section when ever available randomized controlled trials were considered a priority over other trials. Results/conclusions: The drug has excellent penetration into the epidermis and a prolonged retention time following topical application, conferring residual therapeutic activity after treatment cessation. Butenafine possess anti-inflammatory activity too. Topical butenafine 1% cream has been reported to be efficacious for tinea pedis, tinea corporis and tinea cruris in many randomized clinical trials when used for shorter duration. Its efficacy against pityriasis versicolor, seborrheic dermatitis and as anticandidal agent is not yet fully established.

Pheohyphomycosis caused by Exophiala spinifera: a rare occurrence

A 10‐year‐old immunocompetent boy presented with multiple, verrucous, disseminated pheohyphomycotic lesions caused by Exophiala spinifera. The patient was not responsive to combination antifungal therapy (itraconazole, terbinafine, fluconazole) and cryotherapy. As antifungal susceptibility is known to be variable for Exophiala spinifera, in vitro sensitivity testing is recommended before medical treatment. This article reviews, in brief, all cases documented so far in the English literature.

Xanthelasma palpebrarum: a marker of premature atherosclerosis (risk of atherosclerosis in xanthelasma)

Purpose To evaluate the association between xanthelasma palpebrarum (XP) and atherosclerosis by the measurement of carotid intima media thickness (CIMT). In addition, the concurrent association between metabolic syndrome, dyslipidaemia and dyslipoproteinaemia was also assessed. Study design A cross-sectional study was conducted from January 2008 to April 2009 involving 40 patients of XP and an equal number of age, sex and body mass index matched controls. All study subjects underwent CIMT estimation by ultrasonography and were evaluated for metabolic syndrome (obesity, blood pressure, blood glucose, serum lipid profile), non-alcoholic fatty liver disease, apolipoprotein A1 and apolipoprotein B. Results The mean CIMT was significantly higher in XP patients as compared with controls. However, there was no correlation with the extent or the duration of the XP lesions. Prevalence of metabolic syndrome was similar in both groups while non-alcoholic fatty liver disease was more frequent in XP patients as compared with controls (p=0.001). The mean serum cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglyceride levels were similar in the two groups. However, there was significant increase in the mean pro-atherogenic apolipoprotein B and decrease in the anti-atherogenic apolipoprotein A1 levels in XP patients. Conclusions Alteration in apolipoprotein levels (A1 and B) in XP patients may predispose to cutaneous and systemic deposition of lipids, including atherosclerosis. Therefore, XP patients irrespective of their lesion size or serum lipid levels should be screened using CIMT for detection of subclinical atherosclerosis.