D Sukumar

A Comparative Study of the Efficacy of 4% Hydroquinone vs 0.75% Kojic Acid Cream in the Treatment of Facial Melasma.

Background: Melasma is a common acquired cause of facial hyperpigmentation seen predominantly among females with significant psychological and social impact. It is often recalcitrant to treatment. Several topical hypopigmenting agents have been used to combat melasma. Hydroquinone and Kojic Acid are well established monotherapeutic agents for treating melasma. Objectives: This study focuses mainly on the efficacy of once daily application of 4% Hydroquinone and 0.75% Kojic Acid cream (containing 0.75% Kojic acid and 2.5% vitamin C) so as to determine an effective modality of treatment for facial melasma. Materials and Methods: A total number of 60 patients with facial melasma attending the Out-patient department of Dermatology, Venerology and Leprosy, Fr. Muller Medical College Hospital, Mangalore from Oct 2008-April 2010 were studied. Patients were allocated alternately to group A and group B. Group A patients received 4% Hydroquinone cream and group B patient received a Kojic Acid cream (which contained 0.75% Kojic acid and 2.5% vitamin C) and were advised to apply topically once daily at night. Patients were followed up on 4th, 8th and 12th week. At each visit side effects were noted and clinical response to treatment was calculated using the MASI score. Statistical Methods: Chi square test, student ‘t’ test. Results: At the 4th week post treatment evaluation, facial hyperpigmentation responded early to 4% Hydroquinone cream than to 0.75% Kojic Acid cream. At the end of 12 week treatment period, 4% Hydroquinone cream had an overall superiority to 0.75% Kojic Acid cream as a topical hypopigmenting agent. Conclusion: The results of the study show that 4% Hydroquinone cream is a better topical hypopigmenting agent with rapid rate of clinical improvement when compared to 0.75% Kojic Acid cream.

Pyoderma gangrenosum: an Indian perspective

Background.  Pyoderma gangrenosum (PG) is an uncommon, idiopathic, neutrophilic skin disease sometimes associated with systemic diseases. To our knowledge, there have been no case series of PG reported from India.

A comparative study of 10% KOH solution and 5% imiquimod cream for the treatment of Molluscum contagiosum in the pediatric age group

Background: Although Molluscum contagiosum (MC) is a self-limiting condition, active therapy could prevent further spread and improve cosmesis. Most of the available treatment modalities traumatize the lesions and have to be undertaken in the hospital, therefore evoking panic in children. In the quest for an alternative therapy, this study comparing 10% potassium hydroxide (KOH) solution and 5% imiquimod cream was taken up. Aims and Objectives: To compare the efficacy and tolerability of 10% KOH and 5% imiquimod in the treatment of MC. Materials and Methods: This comparative study was conducted over a period of 18 months from October 2011 to March 2013, 40 patients between the age group of 1-18 years with clinically diagnosed MC were divided into two groups (lottery method), 20 patients were treated with 5% imiquimod cream (Group A) and the other 20 were treated with 10% KOH solution (Group B). Patients were followed up on the 4 th , 8 th and 12 th week of treatment. Results: At the end of 12 weeks, out of 20 patients who received 10% KOH, 17 patients showed complete disappearance, whereas out of 20 patients who received 5% imiquimod, only 10 patients showed total clearance of the lesions. Adverse events were more frequent with 10% KOH, pigmentary disturbances being the most common. Conclusion: With only minor adverse effects, 10% KOH is an inexpensive and efficient modality for the treatment of MC in the pediatric age group. Although 5% imiquimod was effective in clearing the lesions with minimal adverse effects, the longer duration required for its efficacy may deter its wider use.

A clinical and mycological study of dermatophytic infections.

Background: Dermatophytoses refer to superficial fungal infection of keratinized tissues caused by keratinophilic dermatophytes. According to observations worldwide, dermatophytoses are the most common of the superficial fungal infections. It is common in tropics and may present in epidemic proportions in areas with high rates of humidity. Although common, the precise size of the problem defies measurement. Aims: The present study was undertaken to assess the clinical profile of dermatophytic infection and to identify the species of fungi that are prevalent in this region. Materials and Methods: A total of 100 patients clinically suspected for dermatophytoses were selected for the study. Direct microscopy in 10% potassium hydroxide (KOH) and culture was done in each case. Results: Out of 100 patients, the maximum were seen in the age groups of 16-30 years. Tinea corporis was the most common clinical type (44.3%) followed by tinea cruris (38.2%). Overall positivity by culture was 39% and by direct microscopy 96%. Conclusion: Trichophyton rubrum was the predominant species isolated (67.5%) in all clinical types followed by Trichophyton mentagrophytes. Culturing the fungus may identify the species, but it is not essential for the diagnosis as it is not a sensitive test.

Mucocutaneous manifestations of chikungunya fever: A study from an epidemic in coastal Karnataka

Background: Chikungunya fever (CF) epidemic has recently re-emerged in India affecting large population. Mucocutaneous manifestations are an important clinical feature of the disease. We have reviewed mucocutaneous manifestations of the disease during a recent epidemic in coastal Karnataka. Patients and Methods Seventy-five “suspect cases” of CF with dermatological manifestations were examined. Results: We categorized the mucocutaneous manifestation into six groups: 1. skin rash, 2. apthae like ulcers, 3. pigmentary changes, 4. desquamation, 5. exacerbation of the existing dermatoses, 6. miscellaneous. Skin rashes were the most commonly observed skin changes followed by apthae like ulcers and pigmentary changes. Desquamation of the skin over the face is a new manifestation observed by us. Conclusion: wide spectrum of mucocutaneous manifestations is observed in CF. We have provided a classification for these manifestations, which may help in better recognition and uniform recording in future.

Clinico-etiological study of 30 erythroderma cases from tertiary center in South India

Background: Erythroderma is a morphological reaction pattern of skin having many underlying causes and finding the etiology helps in the proper management of erythroderma cases. Aim: To evaluate the clinical profile, etiology of erythroderma and to correlate clinical diagnosis with histopathology. Materials and Methods: This study was performed at the department of dermatology, Father Muller Medical College and Hospital, Mangalore, South India. We studied 30 consecutive cases of erythroderma with respect to the epidemiological, clinical and histological data. Clinico-histological correlation was analyzed for etiology of erythroderma. Results: The mean age of onset was 52.3 years with a male to female ratio of 14:1. In addition to erythroderma, other co-existent features included pruritus, fever, lymphadenopathy, and edema. Of the pre-existing dermatoses, psoriasis was the most common (33.3%) disease followed by eczema (20%), atopic dermatitis (6.6%), pityriasis rubra pilaris (3.3%) and drug-induced erythroderma (16.6%). In 16.6% of cases, etiology could not be ascertained. Clinico-histopathological correlation could be established in 73.3% of cases. Conclusion: Clinical features were identical irrespective of etiology. Detailed clinico-histopathological examination helps to establish the etiology of erythroderma.

Cerebriform Cutaneous Lesions in Pemphigus Vegetans.

Pemphigus vegetans is an autoimmune bullous disorder characterized by vegetating lesions commonly over the flexures. A 42-year-old female patient came with pemphigus vegetans presenting with interesting cerebriform morphology of the cutaneous lesions over the flexures. Cerebriform tongue, a morphology with typical pattern of sulci and gyri over dorsum of the tongue is a well-known sign seen in pemphigus vegetans. Interestingly, we noticed the typical sulci and gyri pattern in the skin lesions of pemphigus vegetans over the flexures of the body. This clinical sign can be used as a clue in the diagnosis of pemphigus vegetans. Morphology and physical characteristics are important for the diagnosis of the disease. Clinical signs always give a clue to the probable or possible diagnosis in most of the dermatological conditions.

The clinical spectrum and antibiotic sensitivity patterns of staphylococcal pyodermas in the community and hospital.

Context: The uncontrolled use of antibiotics has resulted in a relentless spread of multiresistant strains of Staphylococcus aureus. There are studies conducted in medical colleges in Chandigarh, Chennai, Mumbai and Vellore comparing pyodermas in the community and hospital setting based on clinical and bacteriological parameters. Aims: This study, conducted over 1½ years from March 2009 to August 2010, aimed at analyzing the clinical spectrum and antibiotic sensitivity pattern of community and hospital-associated (HA) staphylococcal pyoderma. It also assessed the prevalence of methicillin-resistant S. aureus (MRSA) in the community and hospital cohort settings. Subjects and Methods: The study comprised of 200 cases of staphylococcal pyodermas, derived from the community (150 cases) and hospital (50 cases). Patients were evaluated based on their clinical presentation; antibiotic susceptibility was tested using the Kirby-Bauer disk diffusion method. Statistical Analysis Used: Statistical significance between individual attributes between the community and HA staphylococcal pyoderma groups was analyzed using Chi-square test and mean differences using students t-test. Results: Factors associated with community-associated (CA) pyodermas were young age (P = 0.0021), primary pyodermas, and involvement of extremities, while those with HA pyodermas were middle age, secondary pyodermas, and significantly increased body surface involvement (P = 0.041). Incidence of CA-MRSA was 11.3%, while that of HA-MRSA was 18%. Conclusions: A high level of resistance to first-line drugs such as penicillin, ciprofloxacin and cotrimoxazole was observed, more so in the hospital strain than in the community strain. S. aureus demonstrated good susceptibility to cephalosporins. Though the two strains of MRSA differed clinically, they showed 100% sensitivity to vancomycin and linezolid.

A retrospective study of chromomycosis in a tertiary care institution in South India

Background Chromomycosis is a chronic fungal infection that affects the skin and subcutaneous tissue and occurs mainly following trauma. The most frequently isolated agent is Fonsecaea pedrosoi. Objective The aim of this study was to analyze the various epidemiological, clinical, mycological, and treatment aspects of chromomycosis in coastal Karnataka. Materials and methods This is a retrospective analysis of 20 patients with chromomycosis who attended the dermatology outpatient department of a tertiary care institution in coastal Karnataka, South India, from January 2005 to January 2013. Results The disease was found to be more common in male agricultural workers, especially rubber tappers. The lower limbs were more commonly affected (58%), with verrucous lesion being the most common clinical type. The most common species isolated was F. pedrosoi. Histopathological correlation was present in all cases. A good clinical response was seen in patients treated with potassium iodide who were refractory to terbinafine and fluconazole. Conclusion Chromomycosis mainly affects male agricultural workers, especially rubber tappers. Potassium iodide is an effective alternative for the treatment of chromomycosis, especially in a developing country like India.

A case of Reiter's disease exacerbated by lithium

Reiters disease is characterized by the triad of peripheral arthritis, urethritis, and conjunctivitis. A 38-year-old male, who was on treatment with lithium for mania, presented to us with all features of this triad. He was previously diagnosed and treated as seronegative arthritis. However, his symptoms persisted despite therapy. His skin lesions regressed only once lithium was stopped. Lithium is known to exacerbate or precipitate a multitude of dermatological conditions. However, there is no previous reported association of lithium exacerbating preexisting Reiters disease. We report this case as it is the first known association of its kind.