Devinder Mohan Thappa

Pellagra and skin.

Pellagra is a nutritional disorder that occurs as a result of niacin deficiency. 1 The term pellagra is derived from the Italian words “pelle agra” meaning rough skin. 2 It is still endemic in areas of Africa and Asia because of poor nutrition and intake of certain cereals such as maize and jowar (Indian millet): the staple diet. 3,4 This disease, which killed thousands in the United States as recently as 1930, is all but eradicated as a result of great advances in public health in developed countries and improvements in nutrition and enrichment of wheat flour with nicotinic acid. 4 In the present day in Western world, pellagra is confined to individuals who have improper food intake such as psychiatric patients, alcoholics and recluses. 3

Sexually transmitted diseases and sexual lifestyles of long-distance truck drivers: a clinico-epidemiologic study in south India.

Our study objective was to determine the prevalence and pattern of sexually transmitted diseases (STDs) and to study sexual lifestyles of long-distance truck drivers and their assistants in south India. For this, a total of 263 truck drivers/assistants were recruited from the highway clinic from October 1999 to March 2001. All of them were sexually active and heterosexual contact was the predominant mode (99.2%). Two-thirds of them had contact with commercial sex workers (CSWs) and roughly 60% admitted alcohol consumption. One hundred and two participants (38.7%) had various STDs. The positivity rates of HIV, VDRL and HBsAg were 15.9%, 13.3% and 21.2% respectively. The higher median age, education less than primary school level, longer duration of occupation, longer duration of each trip and a previous history of genital ulcer disease were significant risk factors for the acquisition of HIV infection.

Disseminated Cutaneous Rhinosporidiosis

Two cases of longstanding rhinosporidiosis developed widespread asymptomatic nodular skin lesions. Cutaneous examination showed multiple, discrete, sessile and pedunculated, smooth and warty, friable nodular lesions of variable sizes and shapes. Histopathology of representative skin lesions showed hyperplastic epidermis with sporangia containing spores in the upper dermis diagnostic of rhinosporidiosis. Epidemiological data about rhinosporidiosis at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India, is presented. Possible modes of dissemination to the skin and differential diagnosis are discussed in relation to this rare manifestation of rhinosporidiosis.

Nodulocystic acne: oral gugulipid versus tetracycline.

Twenty patients with nodulocystic acne were randomly allocated to one of two treatment schedules: 1) Tetracycline 500 mg or 2) Tab. Gugulipid (equivalent to 25 mg guggulsterone). Both were taken twice daily for 3 months, and both produced a progressive reduction in the lesions in the majority of patients. With tetracycline, the percentage reduction in the inflammatory lesions was 65.2% as compared to 68% with gugulipid; on comparison, this difference was statistically insignificant (P>0.05). Follow‐up at 3 months showed a relapse in 4 cases on tetracyline and 2 cases on gugulipid. An interesting observation was that the patients with oily faces responded remarkably better to gugulipid.

Profile of acne vulgaris―A hospital-based study from South India

BACKGROUND Acne vulgaris is believed to be the most common disease of the skin. There is no Indian study on the profile of acne vulgaris, markers of severe forms of acne vulgaris and a possible correlation between acne vulgaris and markers of androgenicity in females. AIM To study the profile of acne vulgaris, its seasonal variation, relationship with smoking and possible correlation between acne vulgaris and markers of androgenicity in females. METHODS The study was conducted between August 2006 and June 2008. All patients with acne vulgaris who consented to participate in the study were included. The parameters evaluated included age, gender, age of onset, duration of lesions, site of lesions, grade, relation with menstrual cycle, markers of androgenicity, number of acne lesions such as comedones, papules pustules and nodules, number and site of post-acne scarring, post-acne hyperpigmentation, seasonal variation and history of smoking. RESULTS A total of 309 patients with acne vulgaris were included in the study. The frequency of acne vulgaris in our study was 1.068%. Mean age of the study group was 19.78 years. Male to female ratio was 1.25:1. The most common age group involved was 16 to 20 years (59.8%). Mean age of onset was 15.97 years. Face was involved in all the patients, followed by back (28.2%), chest (20.1%), neck (9.4%) and arms (10%). In the older age groups, women were more likely to report having acne vulgaris than men (P = 0.01). The closed comedones outnumbered open comedones by a factor of 4.9:1. A total of 186 patients (60.2%) had grade 1 acne vulgaris, 85 (27.5%) had grade 2 acne, 8 (2.6%) had grade 3 acne and 30 (9.7%) had grade 4 acne vulgaris. There was a higher incidence of scarring (39.5%) and post-acne hyperpigmentation (24.6%) in our study. In female patients, 57.7% had premenstrual flare and 12.4% had cutaneous markers of androgenicity. There was no association between severity of acne vulgaris and other markers of androgenicity (P = 0.108). Seborrheic dermatitis (21.35%) was the most common disease associated. Seasonal variation was observed only in 80 patients (25.9%); 71 patients (23%) exacerbated in summer and 9 patients (2.9%) in winter. Smokers had more severe grade of acne vulgaris compared to nonsmokers (P = 0.001). CONCLUSION This study brings out the clinical profile of acne vulgaris in a tertiary care hospital in South India.

Utility of dermoscopy in alopecia areata.

Background: Alopecia areata (AA) shows several well-defined dermoscopic features which may help in confirming diagnosis in AA. Aims: We carried out a study to examine the dermoscopic features of AA and develop a protocol for diagnosis of AA by dermoscopy. Materials and Methods: Dermoscopy was performed in 66 patients with AA. Hanse HVS-500NP dermoscope (magnification of ×32 and ×140) was used. Results: The mean age of the patients (46 males and 20 females) was 26.85 years. The mean age of onset was 25.15 years. The mean duration of alopecia was 10.3 months. Most common AA in our study was patchy type (57/66, 87.7%). Single patch was seen in 24 patients and multiple patches in 33 patients. Diffuse AA was seen in five patients. Ophiasis and alopecia universalis were seen in two patients each. Nail changes were fine pitting (4), ridging (2), thinning of nail plate (2). Twenty nail dystrophy, distal onycholysis, striate leukonychia and coarse pitting were seen in one patient each. Intralesional triamcinolone acetonide was the most common therapy offered. Others were oral betamethasone minipulse therapy, dexamethasone pulse, minoxidil, anthralin and corticosteroids. The most common dermoscopic finding was yellow dots seen in 54 patients (81.8%), followed by black dots (44 patients, 66.6%), broken hairs (36 patients, 55.4%), short vellus hair (27 patients, 40.9%) and tapering hairs (8 patients, 12.1%). Conclusions: The most common dermoscopic finding of AA in our study was yellow dots, followed by black dots, broken hairs, short vellus hair and tapering hairs. Dermoscopic findings were not affected by the type of AA or the severity of the disease.

Diet in dermatology: revisited.

Diet has an important role to play in many skin disorders, and dermatologists are frequently faced with the difficulty of separating myth from fact when it comes to dietary advice for their patients. Patients in India are often anxious about what foods to consume, and what to avoid, in the hope that, no matter how impractical or difficult this may be, following this dictum will cure their disease. There are certain disorders where one or more components in food are central to the pathogenesis, e.g. dermatitis herpetiformis, wherein dietary restrictions constitute the cornerstone of treatment. A brief list, although not comprehensive, of other disorders where diet may have a role to play includes atopic dermatitis, acne vulgaris, psoriasis vulgaris, pemphigus, urticaria, pruritus, allergic contact dermatitis, fish odor syndrome, toxic oil syndrome, fixed drug eruption, genetic and metabolic disorders (phenylketonuria, tyrosinemia, homocystinuria, galactosemia, Refsums disease, G6PD deficiency, xanthomas, gout and porphyria), nutritional deficiency disorders (kwashiorkar, marasmus, phrynoderma, pellagra, scurvy, acrodermatitis enteropathica, carotenemia and lycopenemia) and miscellaneous disorders such as vitiligo, aphthous ulcers, cutaneous vasculitis and telogen effluvium. From a practical point of view, it will be useful for the dermatologist to keep some dietary information handy to deal with the occasional patient who does not seem to respond in spite of the best, scientific and evidence-based therapy.

Comparative study of trichloroacetic acid versus glycolic acid chemical peels in the treatment of melasma.

BACKGROUND Melasma is a common cause of facial hyperpigmentation with significant cosmetic deformity. Many modalities of treatment are available, but none is satisfactory. AIM This study was designed to compare the therapeutic response of melasma in Indian women to glycolic acid (GA 20-35%) versus trichloroacetic acid (TCA 10-20%) for chemical peeling. METHODS Forty nonpregnant female patients with a minimum melasma area and severity index (MASI) of 10 were recruited in the study. After a detailed history and clinical examination under natural light, MASI was calculated and color photographs were taken of all the patients. The patients were advised to carry out a prepeel program of daily application of 12% GA cream or 0.1% tretinoin at night for 2 weeks. They were then treated with graded concentrations of 20-35% GA facial peel every 15 days in GA group and 10-20% TCA in the second group. RESULTS Objective response to treatment evaluated by reduction in MASI scoring after 12 weeks was by 79% reduction (from 26.6 to 5.6) in GA group and by 73% reduction in TCA group (from 29.1 to 8.2) but this difference was not significant. Patients with epidermal-type melasma showed a better response to treatment than those with mixed-type melasma (P<0.05). Subjective response, as graded by the patient, showed good or very good response in 75% in GA group and 65% in TCA group. No relation of treatment response to age and duration of melasma could be established in this study. CONCLUSIONS A prepeel program of daily application of 12% GA cream at night for 2 weeks, followed by graded increase in GA and TCA concentrations proved to be an equally effective treatment modality for epidermal and mixed melasma. There are hardly any major side effects, and regular use of sunscreens prevents chances of postpeel hyperpigmentation. GA peel is associated with fewer side effects than TCA and has the added advantage of facial rejuvenation.

Angiokeratoma circumscriptum of the oral cavity

Sir, The term angiokeratoma is applied to several distinct unrelated conditions with cutaneous vascular lesions, the histology of which shows super¢cial dermal vascular ectasia with overlying hyperkeratosis of the epidermis. Di¡erent types of angiokeratomas have been described. They are (i) the generalized systemic type ^ angiokeratoma corporis di¡usum of Fabry; (ii) the bilateral form occurring in the dorsa of ¢ngers and toes ^ angiokeratoma of Mibelli; (iii) the localized scrotal form ^ angiokeratoma of Fordyce; (iv) the usually solitary papular angiokertoma; and (v) the multiple papular and plaque like ^ angiokeratoma circumscriptum (1). Though all types di¡er clinically they share similar histological features. They are characterized by hyperkeratosis, acanthosis and dilated capillaries in the papillary dermis, partly or completely enclosed by the papillomatous epidermis. Organized or organizing thrombi are occasionally observed within the dilated capillaries. Moreover, in Fabrys disease and fucosidosis, swollen and vacuolated endothelial cells are also identi¢ed in the vascular spaces. Angiokeratoma circumscriptum presents as multiple purple papules that later become verrucous and may coalesce to form plaques. The lesions are situated typically on the lower leg or foot but can occur on the thigh, buttock or occasionally elsewhere. In this report, we describe a case of angiokeratoma circumscriptum of the tongue that we believe is probably the ¢rst case reported in the literature.

A clinical study of skin changes in pregnancy.

BACKGROUND During pregnancy profound immunologic, metabolic, endocrine and vascular changes occur, that are responsible for the changes of the skin and its appendages, both physiologic and pathologic. AIMS We undertook a clinical study to find out the frequency and pattern of skin changes in pregnant women. METHODS All consecutive pregnant women were included in the study. RESULTS A total of 607 pregnant women were included in this study. Of these, 303 (49.9%) pregnant women were primigravida and 304 (51.1%) were multigravida. Skin changes grouped into: physiological changes (all cases), specific dermatoses (22 cases) and other dermatoses affected by pregnancy (125 cases). Most common physiological changes were pigmentary alterations seen in 555 (91.4%) followed by striae seen in 484 (79.7%) cases. Of the various specific dermatoses of pregnancy, pruritic urticarial papules and plaques of pregnancy (PUPPP) was the most common disorder (14 cases) followed by pruritus gravidarum (5 cases). The most common dermatoses affected by pregnancy were candidal vaginitis (17 cases), acne vulgaris (15 cases), skin tags (15 cases), eczemas (14 cases). CONCLUSION This study brings into focus various skin changes during pregnancy in south India.