Deepashree Daulatabad

Glutathione as a skin whitening agent: Facts, myths, evidence and controversies.

Glutathione is a low molecular weight thiol-tripeptide that plays a prominent role in maintaining intracellular redox balance. In addition to its remarkable antioxidant properties, the discovery of its antimelanogenic properties has led to its promotion as a skin-lightening agent. It is widely used for this indication in some ethnic populations. However, there is a dichotomy between evidence to support its efficacy and safety. The hype around its depigmentary properties may be a marketing gimmick of pharma-cosmeceutical companies. This review focuses on the various aspects of glutathione: its metabolism, mechanism of action and the scientific evidence to evaluate its efficacy as a systemic skin-lightening agent. Glutathione is present intracellularly in its reduced form and plays an important role in various physiological functions. Its skin-lightening effects result from direct as well as indirect inhibition of the tyrosinase enzyme and switching from eumelanin to phaeomelanin production. It is available in oral, parenteral and topical forms. Although the use of intravenous glutathione injections is popular, there is no evidence to prove its efficacy. In fact, the adverse effects caused by intravenous glutathione have led the Food and Drug Administration of Philippines to issue a public warning condemning its use for off-label indications such as skin lightening. Currently, there are three randomized controlled trials that support the skin-lightening effect and good safety profile of topical and oral glutathione. However, key questions such as the duration of treatment, longevity of skin-lightening effect and maintenance protocols remain unanswered. More randomized, double-blind, placebo-controlled trials with larger sample size, long-term follow-up and well-defined efficacy outcomes are warranted to establish the relevance of this molecule in disorders of hyperpigmentation and skin lightening.

Nail tic disorders: Manifestations, pathogenesis and management

Nail tic disorders are classic examples of overlap between the domains of dermatology and psychiatry. They are examples of body-focused repetitive behaviors in which there is an irresistible urge or impulse to perform a certain behavior. The behavior is reinforced as it results in some degree of relief and pleasure. Nail tic disorders are common, yet poorly studied and understood. The literature on nail tic disorders is relatively scarce. Common nail tics include nail biting or onychophagia, onychotillomania and the habit tic deformity. Some uncommon and rare nail tic disorders are onychoteiromania, onychotemnomania, onychodaknomania and bidet nails. Onychophagia is chronic nail biting behavior which usually starts during childhood. It is often regarded as a tension reducing measure. Onychotillomania is recurrent picking and manicuring of the fingernails and/or toenails. In severe cases, it may lead to onychoatrophy due to irreversible scarring of the nail matrix. Very often, they occur in psychologically normal children but may sometimes be associated with anxiety. In severe cases, onychotillomania may be an expression of obsessive-compulsive disorders. Management of nail tic disorders is challenging. Frequent applications of distasteful topical preparations on the nail and periungual skin can discourage patients from biting and chewing their fingernails. Habit-tic deformity can be helped by bandaging the digit daily with permeable adhesive tape. Fluoxetine in high doses can be helpful in interrupting these compulsive disorders in adults. For a complete diagnosis and accurate management, it is imperative to assess the patients mental health and simultaneously treat the underlying psychiatric comorbidity, if any.

Role of nail bed methotrexate injections in isolated nail psoriasis: conventional drug via an unconventional route

Nail psoriasis can be a debilitating condition; however, in patients with isolated nail involvement, the use of toxic systemic therapies such as methotrexate may not be justified. We report on 4 patients (30 involved nails between them), who were treated with injections of methotrexate (0.1 mL of a 25 mg/mL solution) into the nail bed at 3‐weekly intervals. Mean baseline Nail Psoriasis Severity Index (NAPSI) was 4.77 (range 2–8, cumulative score 143; n = 30); dropping successively at each visit to 2.43 (range 0–4, cumulative score 73; n = 30) at 15 weeks. The decline in mean NAPSI from 4.87 to 2.17 was statistically significant (P < 0.001; Friedman analysis). Reported adverse effects were pain, injection site pigmentation and nail bed haemorrhage. Administration of specific targeted therapy to the nail bed may help manage nail psoriasis effectively.

Granular cell tumor in a child: An uncommon cutaneous presentation

Granular cell tumors (GCTs) are uncommon soft tissue tumors which present as papulonodular lesions and are often diagnosed histopathologically. These usually develop in adulthood and are considered to be of Schwann cell origin. Most of the lesions are benign, but malignant lesions with poor prognosis are known to occur. We report a case of GCT in a 9-year-old girl presenting as an isolated lesion simulating an acrochordon. The histopathological and immunohistochemical evaluation showing polygonal granular cells positive for S-100 and neuron-specific enolase, and negative for cytokeratin and desmin helped clinch the diagnosis. Complete excision under local anesthesia was done. The atypical clinical morphology and diagnostic histopathology of this uncommon entity are presented to aid the clinician in recognizing it. These tumors are mostly benign, rarely malignant, with the latter category having a poor prognosis. A near-complete excision is recommended in view of the minimal risk of malignant transformation.

‘Extraction dermoscopy’ as a rapid and innovative diagnostic tool for eruptive vellus hair cyst

1 Sweet RD. An acute febrile neutrophilic dermatosis. Br J Dermatol 1964; 76: 349–56. 2 Surovy AM, Pelivani N, Hegyi I et al. Giant cellulitis-like Sweet syndrome, a new variant of neutrophilic dermatosis. JAMA Dermatology 2013; 149: 79–83. 3 Kaminska EC, Nwaneshiudu AI, Ruiz de Luzuriaga A et al. Giant cellulitis-like Sweet syndrome in the setting of autoimmune disease. J Am Acad Dermatol 2014; 71: e94–5. 4 Koketsu H, Ricotti C, Kerdel FA. Treatment of giant cellulitis-like Sweet syndrome with dapsone. JAMA Dermatology 2014; 150: 457–9. 5 Kroshinsky D, Alloo A, Rothschild B et al. Necrotizing Sweet syndrome: a new variant of neutrophilic dermatosis mimicking necrotizing fasciitis. J Am Acad Dermatol 2012; 67: 945–54.

Azathioprine-associated anagen effluvium

Multiple basal cell carcinomas are uncommon in the Indian population. In our patient, although inability to calculate the cumulative dose of psoralen plus ultraviolet-A makes its relationship with basal cell carcinomas speculative, localization of the tumour over vitiligo patches on sun exposed as well as non-sun exposed sites, the absence of any other known predisposing factor, as well as appearance 1 to 3 years after therapy raises the possibility that psoralen plus ultraviolet-A therapy was responsible. Other unknown factors such as spontaneous mutations may also play a role. Interestingly, the basal cell carcinomas in our patient were pigmented even though they developed over patches of vitiligo. Pigmented basal cell carcinoma contains melanin which is produced by melanocytes that colonize the tumor. These may have been derived from the mutation and proliferation of surviving epidermal melanocytes in the vitiligo patch and these tumor melanocytes may be resistant to the depigmenting factors present in that milieu.

Clinical and serological characteristics of nail psoriasis in Indian patients: A cross-sectional study

Background: Nail involvement in psoriasis is common with a lifetime incidence of 80-90%. It may reflect severity of cutaneous involvement and predict joint disease. Yet it remains, poorly studied and evaluated especially in Indian psoriatic patients. Aim: The present study was undertaken to evaluate clinical and serological profile of nail involvement in psoriasis and to assess quality of life impairment associated with nail involvement in Indian patients. Methods: Consecutive patients with nail psoriasis were assessed for severity of cutaneous disease (psoriasis area severity index score) and nail disease (nail psoriasis severity index score). The impairment in quality of life attributable to nail disease was scored with nail psoriasis quality of life 10 score. All patients were also assessed for joint disease and tested for inflammatory and serological markers as erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and anti-cyclic citrullinated peptide antibodies. Results: In our cohort of 38 patients with nail psoriasis, 9 had concomitant psoriatic arthritis. The mean psoriasis area severity index was 14.4 ± 9.6 (range = 0.4–34). The most commonly recorded psoriatic nail changes were pitting (97.4%), onycholysis (94.7%) and subungual hyperkeratosis (89.5%). The mean nail psoriasis severity index score was 83.2 ± 40.1 (range = 5–156) and mean nail psoriasis quality of life 10 was 1.1 ± 0.4. Erythrocyte sedimentation rate and C-reactive protein were raised in 22/38 (57.9%) and 15/38 (39.5%) patients, respectively; rheumatoid factor was positive in 5/38 (13.2%) and anti-cyclic citrullinated peptide antibody was raised in 4/38 (10.5%) patients. Limitations: Small sample size and lack of a control group. Conclusions: In Indian patients with nail psoriasis, severity of nail involvement was found to be poorly correlated with the extent of cutaneous disease. In addition the impact of nail disease on patients quality of life was found to be minimal. This suggests the need for a quality of life questionnaire suited to the Indian population. Serological markers were raised overall in the study patients and more so in the patients with concomitant arthritis.

Folie a deux and delusional disorder by proxy: an atypical presentation.

Delusion of parasitosis is a rare condition characterised by an individual harbouring the delusion of being infested with insects or parasites. We report a rare and interesting case of delusion of parasitosis presenting as folie a deux, that is, the delusion is shared by both the parents of an 18‐month‐old child, with proxy projection of parental delusion on the child. The case highlights the rare concomitant occurrence of two psychocutaneous disorders and emphasizes the importance of early recognition and appropriate intervention to safeguard the well‐being of the child.

Significance of anti-cyclic citrullinated peptide autoantibodies in immune-mediated inflammatory skin disorders with and without arthritis

Background: Anti-cyclic citrullinated peptides (CCPs) are autoantibodies directed against citrullinated peptides. Rheumatoid factor (RF), an antibody against the Fc portion of IgG, is known to form immune complexes and contribute to the etiopathogenesis of various skin disorders. C-reactive protein (CRP), an acute-phase protein, increases following secretion of interleukin-6 from macrophages and T cells. Anti-CCP, RF, and CRP are well-established immune-markers, their diagnostic potential in immune-mediated skin disorders remains less widely studied. Aims and Objectives: To determine the correlation between anti-CCP, RF, and CRP in immune-mediated inflammatory skin diseases. Materials and Methods: About 61 clinically diagnosed cases of various immune-mediated skin diseases (psoriasis [n = 38], connective tissue diseases such as systemic lupus erythematosus and systemic sclerosis [n = 14], and immunobullous disorders including pemphigus vulgaris and pemphigus foliaceus [n = 9]) were included in the study. These patients were subclassified on the basis of presence or absence of arthritis. Arthritis was present in nine cases of psoriasis and seven connective tissue disorder patients. Detection of serum anti-CCP was done using enzyme-linked immunosorbent assay, whereas CRP and RF levels were detected using latex agglutination technique. Results: Of the 61 specimens, 14.75% had elevated serum anti-CCP levels. RF and CRP levels were elevated in 18.03% and 39.34% specimens, respectively. RF was elevated in 13.16% of inflammatory and 42.88% of connective tissue disorders, whereas anti-CCP was raised in 10.53% of inflammatory and 35.71% of connective tissue disorders. CRP positivity was highest in connective tissue disorders (50%), followed by 39.47% in inflammatory and 22.22% in immunobullous conditions. In none of the immunobullous patients, anti-CCP or RF levels were found to be elevated. Association of the presence of arthritis with elevated anti-CCP was found to be statistically significant. Conclusions: Although anti-CCP, RF, and CRP levels are valuable markers of chronic immune-mediated skin disorders, elaborate studies enrolling a larger number of patients are required to validate these diagnostic markers.

BCG vaccine for immunotherapy in warts: is it really safe in a tuberculosis endemic area?

Management of recurrent and or recalcitrant warts can be a therapeutic challenge and in such cases invoking bodys own immunity may help to overcome the present episode and also prevent recurrences. Bacilli Calmette Geurin (BCG) immunotherapy has long been considered to be an effective and safe modality in such cases. We present a series of seven cases treated with BCG immunotherapy wherein a single dose of BCG caused regression of wart in 85.7% patients and complete resolution was evident in 28.6% patients. However, the development of adverse effects precluded any further dosages in four of seven (57.1%) patients. This raises serious concern on the safety of this therapeutic modality, especially in a population endemic to tuberculosis.