Arun Agarwalla

Tinea capitis in eastern Nepal

Background  Tinea capitis is an increasing public health concern throughout the world. The clinical types and etiological agents vary from time to time and place to place. This study was undertaken to identify the etiological agents and to determine the clinico‐etiological correlation of tinea capitis in eastern Nepal.

Dapsone hypersensitivity syndrome: a clinico-epidemiological review.

Diaminodiphenyl sulphone (dapsone) is a drug of choice in the treatment of leprosy. It is also useful for the treatment of many neutrophilic and other dermatoses. Dapsone hypersensitivity syndrome is a rare but well recognized serious adverse effect characterized by fever, skin rashes, generalized lymphadenopathy, hepatitis, and hepato‐splenomegaly. Twenty‐six patients with dapsone hypersensitivity syndrome were studied for clinical profile, outcome, and prognosis. The male:female ratio was 2.2:1, and the mean age was 33.19 years (range 13 to 64 years). The interval between start of dapsone therapy and appearance of symptoms varied from 2–7 weeks (mean 29.82 days). Twenty‐four patients received dapsone as a part of multi‐drug therapy for leprosy; the other two patients received dapsone for lichen planus and acne vulgaris. Exfoliative dermatitis was the most common cutaneous manifestation followed by erythematous maculo‐papular eruption and Stevens‐Johnson syndrome‐like lesion. The other common systemic manifestations were: fever (26 cases), itching (22 cases), lymphadenopathy (21 cases), jaundice (21 cases), pallor (20 cases), hepatomegaly (19 cases), and pedal edema (14 cases). Investigation profile revealed elevated levels of serum liver enzymes in 100% of patients, elevated erythrocyte sedimentation rate in 92.3%, raised billirubin in 84.6%, leucocytosis in 69.23%, low hemoglobin (<9 gm/dl) in 46.15% and hypoproteinemia in 42.3%. Eosinophilia, hemolytic anemia, and reticulocytosis count were found in 4 patients each. All the patinents had favorable outcomes except three who died due to hepatic failure. Medical personnel must be aware of this potentially fatal syndrome, because it can cause considerable morbidity and mortality.

A Study from Nepal Showing No Correlation between Lichen Planus and Hepatitis B and C Viruses

A total number of 86 cases of Lichen planus (LP) were seen over a period of one and a half years. This constituted 0.58% of 14833 new dermatological patients seen. Hepatitis B and C viral (HBV & HCV) serology was carried out in 64 patients and 43 age and sex matched controls. In the examined patients, 35 (54.27%) had the skin lesions only. Oral lesions were present in 15 (23.4%) of the patients in addition to skin lesions, while 14 (21.9%) had only oral involvement. Serology for HBsAg and HCV was negative in all types of LP patients and the controls. In Nepal, HBV and HCV seem to be not important in the pathogenesis of LP.

Post-kala-azar dermal leishmaniasis in Nepal.

Abstract

Acne in Becker's nevus

An 18‐year‐old man presented with a progressively enlarging, asymptomatic, well‐demarcated, irregular, hyperpigmented patch, 13 cm × 11 cm, on the anterior aspect of the chest below the left clavicular region, with a few small macules at the periphery, of 2 years duration. After 18 months, multiple, discrete, erythematous papules and comedones developed over the patch ( Fig. 1 ). A few melanocytic nevi were present in and around the patch. A clinical diagnosis of Beckers nevus with acne vulgaris was made. A skin biopsy from the patch showed acanthosis, elongated rete ridges, increased pigmentation in the basal layer, and a mild perivascular lymphocytic infiltrate in the upper and lower dermis with few melanophages in the dermis. Histopathology of the comedone revealed slight acanthosis, irregular elongation of the rete ridges, and hyperpigmentation of the basal layer of the epidermis. Multiple melanophages were seen in the upper dermis. In the mid‐dermis, a ruptured closed comedone was seen. The follicular lumen contained a plug of loosely arranged keratinized cells, sebaceous material, and bacterial colonies. Aggregates of neutrophils were found at the site of rupture of the follicular wall. There was a mild perivascular lymphocytic infiltrate in the upper and lower dermis ( Fig. 2 ). These features confirmed the diagnosis of Beckers nevus with acne vulgaris. The acne was treated with 0.05% tretinoin and 2% erythromycin creams. After 2 months of treatment, all the acne lesions subsided. On further follow‐up, the patient had relapse of the acne lesions over the patch with the discontinuation of treatment. A few new lesions also appeared on the face. The treatment was restarted, but the patient was lost to follow‐up.

Lichen planus after HBV vaccination in a child: a case report from Nepal.

Vaccination against hepatitis B virus has rarely been associated with lichen planus. We report a case of this kind in a child from Nepal. A 12‐year‐old boy had developed generalized itchy violaceous papules and plaques six weeks after the second dose of hepatitis B virus vaccine. Serum HBsAg and HBeAb were negative, but HBsAb was positive. New crops of generalized, similar eruptions developed after the booster dose of vaccine. All the lesions resolved within three months of systemic steroid therapy. There was no recurrence after one year of follow up. Awareness of such an association is necessary, especially in children, because vaccination campaigns are increasing.

Port-wine-stain (nevus flammeus), congenital Becker's nevus, café-au-lait-macule and lentigines: phakomatosis pigmentovascularis type Ia--a new combination.

A 16‐year‐old male had brown macules in a geographic pattern with increased terminal hair on the back and dusky red partially blanchable non progressing macules on his left thigh since birth. Clinical diagnoses of Beckers nevus and port‐wine‐stain were made and confirmed histopathologically. In addition, he had multiple lentigines on the face and trunk and a single café‐au‐lait‐macule on his chest.

Stevens‐Johnson Syndrome with Idiopathic Thrombocytopenic Purpura Treated with Dexamethasone Pulse Therapy

Stevens‐Johnson syndrome (SJS) is a severe, episodic, acute, mucocutaneous hypersensitivity reaction often caused by drugs. We herewith report a case of SJS with idiopathic thrombocytopenic purpura (ITP) that did not respond to daily oral prednisolone therapy. When treated with dexamethasone pulse therapy, the response was found to be very good. Therefore, we concluded that dexamethasone pulse therapy can be a good and an effective alternative therapy for treatment of such patients. However, to establish its role, further trials in more patients are needed.

Basal cell carcinoma arising in a localized linear verrucous epidermal naevus

dermatitis or bacterial and mycological infections (1). BTXA has been used recently to treat focal hyperhidrosis (gustatory sweating, palmo-plantar and axillary hyperhidrosis) (4, 5). There are no data available for the treatment of stump hyperhidrosis. We used BTXA for stump hyperhidrosis in a dosage comparable to that used in palmar hyperhidrosis, i.e. 100 U of Botox. The treatment was very effective not only for focal hyperhidrosis of the stump but it also showed a preventive effect on the associated eczema. In another study with tap water iontophoresis for hyperhidrotic hand eczema, it could be demonstrated that effective treatment of hyperhidrosis is an important factor for prolongation of disease-free interval in atopic eczema and contact dermatitis (9). Further studies should be performed to investigate this positive side-effect of hyperhidrosis treatment.

Sexual habits and clinico-etiological profile of sexually transmitted diseases in Nepal.

A total of 100 patients giving histories suggestive of sexually transmitted disease (STDs) and attending the dermatology OPD at BPKIHS (B.P. Koirala Institute of Health Sciences) in Nepal over a period of one year from 1st July 1999 to 30th June 2000 were included in this study. Out of 10,400 new dermatology cases, a total of 100 cases (0.96%) of STDs were seen. Of these 73 were males, and the majority (53%) were in the age group of 21–30 years. Most of the patients were from Sunsari district (54%). The most common profession (21%) was businessman followed by housewife (19%). The most common age for first sexual contact was 16 to 19 years (45%). Eleven percent had their first sexual contact at the age of 15 or below 15 years. Premarital sexual exposure was recorded in 17% of the unmarried males. There were only 3 homosexuals and 1 bisexual patient. Multiple contacts were recorded in 55% of the patients. The most common source of contact was a commercial sex worker in 34.15%. Condoms were always used by only 7%. The various types of sexually trasmitted diseases (STDs) were syphilis (31%) followed by condylomata acuminata (16%), herpes genitalis (15%), gonorrhoea (9%), and mixed infections (12%). Despite their varied sexual behavior, none of the patients were HIV positive; however, it is always advisable to screen all STD patients for HIV antibody.