Dipankar De

Systemic Methotrexate Treatment in Childhood Psoriasis: Further Experience in 24 Children from India

Abstract:  Well‐designed studies on systemic therapeutic modalities for severe psoriasis in children are rare. Children with severe disease are treated with the support of data extrapolated from that in adult, although management in them differs from adults in several important aspects. Like other systemic modalities, data regarding the use of methotrexate in the treatment of childhood psoriasis is meager. This study aims to analyze the efficacy and safety of methotrexate in severe or disabling childhood psoriasis. The records of all the patients <18 years of age treated with systemic methotrexate at the psoriasis clinic of our institute from January 1993 to December 2006 were retrieved. Information regarding demographic profile, disease characteristics, response to treatment, side effects, etc. was noted from predesigned clinic proforma. Indications of methotrexate use were baseline psoriasis area and severity index (PASI) >10, disease refractory to conventional therapies and disabling psoriasis even though the psoriasis area and severity index was <10. Clinical status of patients was assessed at weekly intervals for the first 2 weeks, fortnightly during next month and then monthly. Response to therapy was graded as good (50–75% decrease in PASI) and excellent (>75% decrease in PASI). Laboratory investigations to detect methotrexate induced toxicity were performed at regular intervals. Of the 29 patients treated with methotrexate, 24 were eligible for the final data analysis. Indication for the institution of methotrexate therapy was severe disease, viz., extensive recalcitrant plaque type psoriasis in 17 patients, erythroderma and generalized pustular psoriasis of von‐Zumbusch type in three patients each and severe disabling palmo‐plantar involvement along with chronic plaque lesions in one patient. Response to therapy was excellent (>75% decrease in PASI) in all but two patients. The mean time to control the disease, i.e., 50% reduction in PASI was 5.1 weeks. Mean total cumulative dose of methotrexate in the first episode was 215 mg. The duration of remission could be calculated in nine patients only, varying from 1.5 months to 3 years. Side effects were mild, observed in nine children, which included nausea, vomiting, and loss of appetite. Methotrexate is an effective, cheap, easily available, and reasonably safe drug to be used in severe childhood psoriasis under an expert supervision and laboratory monitoring.

Histoid leprosy: a retrospective study of 40 cases from India.

Background  Rare variants of leprosy pose a diagnostic challenge even to astute clinicians and histoid leprosy is one such form of disease with unique clinical and histopathological features. There are very few large series on this entity, mainly reported from India.

Pemphigus in India

Pemphigus is a chronic epidermal immunobullous disease with potentially fatal outcome. The journey of literature on pemphigus in India has come a long way in last five decades. Pemphigus in Indian patients has unique genetic, clinical, and epidemiological differences from those in the Western countries. Corticosteroids remain the mainstay of treatment for pemphigus. Dexamethasone-cyclophosphamide pulse therapy has revolutionized the management of pemphigus in India and abroad for nearly 3 decades now. Corticosteroid-based treatment, along with adjuvants, has significantly brought down the high mortality rates that had been observed in precorticosteroid era. Present day research is largely based on elucidating the pathogenesis beyond the antidesmoglein antibodies, and newer diagnostic and treatment approaches. In this article, we review various aspects of literature on pemphigus in India, on Indians abroad, or literature from other countries that are considered relevant to the topic.

Contact dermatitis to hair dye: An update

Exposure to hair dyes has long been known as a significant risk factor for development of allergic contact dermatitis among the exposed population as these lead to severe eczema of face and upper trunk in the consumer and hand eczema in hair-dressers. Currently, para-phenylenediamine (PPD) is the main ingredient used in permanent hair color products in the market and is the most important allergen. Prevalence of PPD sensitization is high in patients with contact dermatitis across all continents, with hair dye use being the commonest cause. In order to decrease the burden of disease, use of alternative natural dyeing agents among consumers and use of barrier neoprene gloves among hairdressers should be encouraged apart from stringent legislation to reduce the amount of PPD reaching the consumer.

Airborne contact dermatitis - current perspectives in etiopathogenesis and management

The increasing recognition of occupational origin of airborne contact dermatitis has brought the focus on the variety of irritants, which can present with this typical morphological picture. At the same time, airborne allergic contact dermatitis secondary to plant antigens, especially to Compositae family, continues to be rampant in many parts of the world, especially in the Indian subcontinent. The recognition of the contactant may be difficult to ascertain and the treatment may be even more difficult. The present review focuses on the epidemiological, clinical and therapeutic issues in airborne contact dermatitis.

Comparative efficacy of thalidomide and prednisolone in the treatment of moderate to severe erythema nodosum leprosum: A randomized study

The present study was undertaken to compare the efficacy and safety of thalidomide to that of oral prednisolone in the treatment of moderate to severe type 2 lepra reaction. Sixty patients with a histologically confirmed diagnosis of erythema nodosum leprosum with a clinical score of 4 or more (i.e. moderate to severe type 2 reaction) were randomly allocated to two groups comprising 30 patients each. Group 1 patients were given thalidomide at a dose of 300 mg/day for 1 week and the dose was gradually reduced, and Group 2 received prednisolone 40 mg daily for 2 weeks, which was tapered by 10 mg every 2 weeks. Thalidomide induced a faster clinical response (cutaneous as well as systemic) compared with prednisolone. Patients taking thalidomide had fewer relapses and a longer period of remission than those receiving prednisolone.

Narrowband ultraviolet B versus psoralen plus ultraviolet A therapy for severe plaque psoriasis: an Indian perspective

There is a dearth of studies comparing the efficacy of psoralen ultraviolet A (PUVA) and narrowband (NB)‐UVB in psoriasis in South Asian patients. Patients having plaque psoriasis with > 20% body surface area involvement were randomly assigned to one of two groups (group A: NB‐UVB, group B: PUVA). The response to treatment was assessed by the Psoriasis Area and Severity Index (PASI) at baseline and every 2 weeks thereafter. The maximum possible treatment duration was 16 weeks. In total, 43 patients (21 NB‐UVB, 22 PUVA) completed the study. Marked improvement was seen in 80.9% of the patients in group A and 81.8% in group B (NS: P > 0.05). The mean ± SD time taken to achieve marked improvement was 9.9 ± 3.3 and 9.9 ± 3.5 weeks, respectively. In total, 29 patients were available for the analysis of the remission data at 6 months after treatment completion; 26.7% of the patients in group A and 42.8% in group B were in remission (NS: P > 0.05). Both methods seem to be equally effective in achieving clearance and maintaining remission of severe chronic plaque psoriasis in patients with Fitzpatrick skin type 4 and 5.

Lichen planus in children

Lichen planus in children is considered to be rare overall, though it does not appear to be so in Indian subcontinent. Most of the large studies on lichen planus in children have been undertaken in India. We review here the epidemiology, pathogenesis, clinical features, diagnosis, management and prognosis pertaining to lichen planus in children with emphasis on studies published from India.

Narrowband ultraviolet B in the treatment of psoriasis: The journey so far!

Ever since artificial TL-01 lamps were developed, narrowband ultraviolet B (NBUVB) has gained giant strides in dermatology. Psoriasis is one of the common indications for the use of NBUVB in present day dermatology. We discuss here the evolution of NBUVB, its mechanism of action pertaining to psoriasis, indications and contraindications, dosimetry, complications of NBUVB while being used in patients with psoriasis, its merits and demerits in comparison with broadband UVB and psoralen+UVA (PUVA), and recent developments in the delivery system of NBUVB.

Insulin Resistance and Metabolic Syndrome in Young Men With Acne.

INTRODUCTION Robust evidence of the association of insulin resistance and metabolic syndrome with acne in male patients is lacking. OBJECTIVE To assess the prevalence of metabolic syndrome and insulin resistance in male patients 20 years or older with acne. DESIGN, SETTING, AND PARTICIPANTS We performed a cross-sectional study in 100 male patients with acne and 100 age-matched male controls without acne from a dermatology outpatient department of a tertiary care institute. Postadolescent patients were recruited only to negate the effects of physiologic insulin resistance that are seen at the time of puberty and adolescence. Twenty-five patients were included in each of the 4 individual severity groups according to the Global Acne Grading System and were age matched to 100 male controls without acne. EXPOSURES Clinical examination, Global Acne Rating System, National Cholesterol Education Programme Adult Treatment Panel III (NCEP-ATP III), and Homeostasis Model Assessment-Insulin Resistance (HOMA-IR). MAIN OUTCOMES AND MEASURES Metabolic syndrome was diagnosed as per the criteria of the modified NCEP-ATP III. Insulin resistance was assessed by the HOMA-IR. A HOMA-IR value greater than 2.5 was arbitrarily considered as insulin resistance. RESULTS Prevalence of insulin resistance was significantly higher in cases (22%) compared with controls (11%) (P = .03). The prevalence of metabolic syndrome was comparable between cases (17%) and controls (9%) (P = .09). Prevalence of insulin resistance and metabolic syndrome did not differ significantly among the acne severity groups. CONCLUSIONS AND RELEVANCE Postadolescent male patients with acne more commonly have insulin resistance. This resistance may be a stage of prediabetes, and the patients may develop hyperinsulinemia or type 2 diabetes in the future. These patients should be followed up for a prolonged time to determine whether they develop conditions associated with insulin resistance.