Debabrata Bandyopadhyay

Autologous serum therapy in chronic urticaria: A promising complement to antihistamines

Background: Chronic urticaria (CU) is a vexing problem and patients of CU suffer from the morbidity that arise from irritable itch and weals and are also subjected to a huge antihistamine pill burden. The symptoms are more in autoreactive urticaria (AU) where auto-antibodies in blood flares-up the condition. Search for newer effective modalities which can reduce pill burden is a felt need. Aims: This study evaluates the effectiveness of autologous serum therapy (AST) in CU and also determines its usefulness in AU. Materials and Methods: Double blind, parallel group, randomized, controlled study. Fifty four patients were given AST and 57 patients were given injection normal saline (placebo), along with cetirizine in an on-demand basis in both groups. AST/Placebo was given weekly for nine weeks and followed-up for a total period of 24 weeks. AU was diagnosed by autologous serum skin test. Urticaria total severity score (TSS), Urticaria activity score (UAS), Dermatologic life quality index (DLQI) was used as primary effectiveness variables. Safety parameters assessed were the spontaneously reported adverse events and laboratory parameters. Results: TSS showed significant improvement from baseline, 7th week and 8th week onwards in AST group and placebo group respectively. Group comparison showed significant improvement 4th week onwards. UAS showed similar results. DLQI showed significant improvement in AST group compared to placebo at the end of study. Both AU and non-AU patients showed comparable improvement of TSS. Conclusion: AST shows promise in treatment of urticaria regardless of the autoreactive nature.

Huge nevus lipomatosus cutaneous superficialis on back: An unusual presentation

Nevus lipomatosus cutaneous superficialis (NLCS) is a benign dermatosis, histologically characterized by the presence of mature ectopic adipocytes in the dermis. We hereby report a case of a 10-year-old boy who presented with multiple huge swellings on the scapular regions and lower back. The lesions were surmounted by small papules, along with peau-d orange appearance at places. Histology showed features consistent with NLCS. The case is being reported for the unusual clinical presentation.

Granular Cell Tumor: An Uncommon Benign Neoplasm

Granular cell tumor is a distinctly rare neoplasm of neural sheath origin. It mainly presents as a solitary asymptomatic swelling in the oral cavity, skin, and rarely internal organs in the middle age. Histopathology is characteristic, showing polyhedral cells containing numerous fine eosinophilic granules with indistinct cell margins. We present a case of granular cell tumor on the back of a 48-year-old woman which was painful, mimicking an adnexal tumor.

Juvenile pemphigoid nodularis: Report of a rare case

Bullous pemphigoid is an autoimmune blistering disease that is rare in childhood. Pemphigoid nodularis is a variant of BP that is exceedingly rare in children. Pemphigoid nodularis is characterized by overlapping clinical features of both prurigo nodularis and BP. We report here a case of pemphigoid nodularis in an 11-year-old boy.

Effectiveness, safety and tolerability of cyclosporine versus supportive treatment in Stevens–Johnson Syndrome/Toxic Epidermal Necrolysis: A record-based study

Background: Toxic epidermal necrolysis and Stevens–Johnson syndrome comprise life-threatening, drug-induced mucocutaneous disease spectrum. Interest in cyclosporine, a calcineurin inhibitor that can block the function of T-cells, has increased with the discovery of the importance of granulysin in apoptosis in toxic epidermal necrolysis. In our hospital, cyclosporine is given to Stevens–Johnson syndrome/toxic epidermal necrolysis patients as an adjunctive therapy. Aims: This study is an observational, record-based study comparing the effectiveness and safety of patients receiving cyclosporine versus only supportive therapy. Methodology: Medical records as bed-head tickets and laboratory investigation reports of Stevens–Johnson syndrome/toxic epidermal necrolysis patients admitted in the hospital over a period of 1 year were collected. Data regarding clinico-demographic profile, suspected drug causing Stevens–Johnsons syndrome/toxic epidermal necrolysis, SCORTEN, body surface area involved, treatment received and outcome were obtained. Results: Twenty-eight patients were analyzed. Nineteen belonged to the cyclosporine group (supportive treatment + cyclosporine), nine to supportive treatment only group. Among the suspected drugs, antiepileptics formed the major group (28.6%). Five patients in the supportive only group and one in the cyclosporine group died. Time for stabilization and reepithelialization and duration of recovery were significantly lower in the cyclosporine group (P < 0.001, P= 0.007, P= 0.01, respectively). The standardized mortality ratio was 0.32 in cyclosporine group which is nearly 3.3 times lower than the only supportive treatment. Limitations: As it was a record-based study, certain confounding factors (serum blood urea nitrogen) could not be adjusted. Conclusion: Cyclosporine (5 mg/kg/day) for 10 days from onset of Stevens–Johnson syndrome/toxic epidermal necrolysis may decrease the risk of dying, may provide faster healing of lesions and might lead to early discharge from hospital.

Progressive cribriform and zosteriform hyperpigmentation.

Progressive cribriform and zosteriform hyperpigmentation (PCZH) is a skin disease first described by Rower et al.1 in 1978. Since then, several cases have been published in Korea but only 3 articles in the dermatology literature in English.2--4 This letter reports the case of a woman with hyperpigmented lesions on the right arm and on the right side of the trunk since childhood. These lesions were consistent with a diagnosis of PCZH. The woman, aged 54 years, was white and had a personal history of fibromyalgia and asthma. She attended the clinic because of an asymptomatic hyperpigmented lesion on the back that had been present since she was 9 years old. Examination revealed several macular lesions with a homogeneous brown color and well-defined but irregular borders, grouped in a segmental pattern on normal skin on the right flank and arm, and the right side of the back and abdomen. These lesions did not cross the midline of the trunk (Figs. 1 and 2). No café-au-lait spots or neurofibromas were seen on unaffected skin. The patient did not recall any rash or prior trauma of the affected area although the lesions did increase in size in the first years after onset. She did not have any extracutaneous abnormalities or a family history of neurofibromatosis or similar skin lesions. A biopsy was taken from the affected area of the back. Histopathology showed an increase in cytoplasmic pigmentation of the cells of the basal epidermal layer (Fig. 3). In view of the clinical and histologic characteristics, a diagnosis of PCZH was made. Rower et al.1 reported 5 patients with pigmentary abnormalities with certain characteristics in common that constituted the diagnostic criteria for PCZH. These characteristics were uniform and cribriform brown macular hyperpigmentation with a zosteriform distribution; a his-

Safety and effectiveness of autoinoculation therapy in cutaneous warts: A double ‑ blind, randomized, placebo ‑ controlled study

BACKGROUND In spite of the availability of multiple treatment options, viral warts are known for their persistence and recurrence, causing frustration to patients and treating physicians. AIMS To study the effectiveness and safety of autoinoculation as a treatment modality in cutaneous warts. METHODS A double-blind, placebo-controlled study was carried out. In the treatment group, full-thickness warty tissue was excised, minced and implanted in a small dermal pocket. In the control group, warty tissue was only excised and not implanted, though a dermal pocket was made. Patients were evaluated every four weeks with lesion counts. The procedure was repeated at 4 and 8 weeks. Response was assessed at each visit and at 12 weeks. RESULTS Forty-eight patients with cutaneous warts (male: female=32:16) were randomized into autoinoculation and control groups. The number of warts at baseline was comparable in both groups (P=0.293). Reduction in the number of warts was significantly more in the autoinoculation group (8.50±13.88) than in the control group (10.04±5.80) from 8 weeks onwards (P=0.010). Complete resolution occurred only in the autoinoculation group, in 62.5% of cases. Adverse effects were seen in 11 patients, including infection of the donor site (5 cases), keloid formation (3) and hypopigmentation (3). CONCLUSION Autoinoculation may be an effective therapeutic modality for cutaneous warts and two sessions may be required for optimum results.

Rational use of drugs in dermatology: A paradigm lost?

What is Rational Therapy? The World Health Organization (WHO) has defined rational use of drugs as: “Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community.”1 This is also referred to, in brief, as the five ‘right’s, i.e., the right drug at the right dose by the right route at the right time for the right patient.2

Immunotherapy in viral warts with intradermal Bacillus Calmette–Guerin vaccine versus intradermal tuberculin purified protein derivative: A double-blind, randomized controlled trial comparing effectiveness and safety in a tertiary care center in Eastern India

Background: Current therapeutic modalities for viral warts are mostly ablative and are limited by high recurrence rates besides being unsuitable for numerous lesions. Immunotherapy has the potential to overcome these limitations. Aims: The aim of this study was to compare the effectiveness and safety of Bacillus Calmette–Guerin vaccine versus tuberculin purified protein derivative in the immunotherapy of warts. Methods: Patients received three doses of 0.1 ml of Bacillus Calmette–Guerin vaccine or tuberculin purified protein derivative intradermally over the deltoid region at 4-weekly intervals. They were followed-up for another month. Number of warts, complete cure rates and quality of life were assessed. Results: A total of 60 patients were included. Complete clearance was noted in 16 (48.5%) out of 33 patients in the Bacillus Calmette–Guerin group and in 5 (18.5%) out of 27 in the tuberculin purified protein derivative group (P = 0.121). The number of lesions reduced statistically significantly from baseline in both the groups (P < 0.001) from the first follow-up visit onward (P < 0.05). The reduction was statistically significantly more in the Bacillus Calmette–Guerin group than in the tuberculin purified protein derivative group from the second follow-up onward. Dermatologic life quality index improved statistically significantly with both treatments. Adverse events (pain during injection, abscess formation and scarring at injection site) were more frequent with Bacillus Calmette–Guerin. No recurrence was seen after lesions cleared. Limitations: Patients were not followed up for more than 4 weeks after treatment. We could not estimate the cytokine levels or the peripheral blood mononuclear cell proliferation in response to Bacillus Calmette–Guerin/tuberculin purified protein derivative injections. Conclusion: Both intradermal Bacillus Calmette–Guerin and tuberculin purified protein derivative hold promise in the treatment of viral warts. Bacillus Calmette–Guerin may be more effective, though it had more adverse events in our study.

Metastatic tubercular abscess associated with bone and lymph node involvement

A 13‐year‐old malnourished girl presented with multiple abscesses predominantly involving her upper and lower extremities for the last 2 years. She had multiple, variably sized, subcutaneous discharging abscesses on the upper extremity, lower extremity and neck [Figures 1 and 2]. The lesions were fluctuant and non‐tender without any sign of inflammation. Matted, enlarged lymph nodes were noted in the cervical [Figure 3] and inguinal regions [Figure 4]. Scars were observed at the sites of previous drainage. She started developing these abscesses on her neck and extremities which progressively increased in size. They had been drained unsuccessfully, only to reappear again. She also received multiple courses of systemic antibiotics and antifungals with no appreciable improvement. There was no history of fever, cough and breathlessness at presentation. The past history revealed an episode of pulmonary tuberculosis, five years back, along with weight loss. Family history was unremarkable. The patient had not been immunized with bacillus Calmette–Guérin (BCG) vaccine. There was pallor, and malnutrition (body mass index 15.5 kg/m2); the remainder of the general examination was normal.