Kamal Aggarwal

Narrow‐band UV‐B phototherapy in childhood psoriasis

Seventy children with psoriasis attended the Outpatient Department of Dermatology, Post Graduate Institute of Medical Sciences, Rohtak, India over a period of 2 years (2003–2005). Of these, 20 children fulfilling the recruitment criterion were included in a hospital-based, prospective trial of the efficacy and safety of NB UV-B phototherapy in childhood psoriasis. Parents gave informed consent. Twenty children (16 boys and four girls), aged 6–14 years, with psoriasis involving more than 20% of the body surface area, were recruited for the study. Our patients belonged to skin type IV. 4 The disease duration was in the range 3 months to 3 years. Patients with a history of photoaggravation or photosensitivity, and patients on systemic treatment or UV therapy during the 8 weeks preceding the study, were excluded. A whole-body NB UV-B phototherapy unit containing 16 TL-01 fluorescent tubes of 100 W each as a source of irradiation, delivering UV-B in the range 310–315 nm with a peak of 312 nm, was used. We found that the determination of the minimal erythema dose (MED) 5 can be too long and exhausting in children, and so it was not used as a routine method. The initial dose of UV-B was determined on the basis of the patient’s skin type according to the classification of Pathak et al . 6 (Table 1). NB UV-B therapy was administered twice a week on nonconsecutive days with an initial dose of 50 mJ and increments of 10% at each session. The dose was not increased if there was any trace of erythema. All patients used photoprotective eye wear and the genitalia were shielded during therapy. All topical psoriasis therapies, other than emollients and scalp therapies, were discontinued. The disease assessment was performed using the Psoriasis Area Severity Index (PASI) score. 7 Scoring was performed at baseline (0 weeks) and at 4, 8, and 12 weeks of treatment. An Table 1 Initial doses of UV-B and UV-A according to skin type

Contact Allergies to Cosmetics: Testing with 52 Cosmetic Ingredients and Personal Products

Fifty patients of both sexes with clinically suspected cosmetic dermatitis were subjected to patch testing with a cosmetic and fragrance series, approved by the Contact and Occupational Dermatosis Forum of India (CODFI), and with selected allergens from the Indian Standard Series (ISS). Most of these patients were young adults between 10–29 years; the mean age was 27.5 years. The majority of the patients had cosmetic dermatitis of <1 year duration (68%). The occupational profiles of the patients included students (46%), housewives (18%), teachers (10%) and laborers (4%). A miscellaneous group, comprised of tailors, farmers, staff nurses, beauticians, jewellers and engineers, accounted for the remaining 22%. The most commonly involved site was the face, followed by the forehead, neck and scalp. Patch testing of these patients revealed that, out of the 50 subjects tested, thirty‐three (66%) reacted to one or more allergens. Fragrance components were the most common offending allergen (51.5%) followed by preservatives (39.3%), paraphenylenediamine (PPD) (21.2%), and cetrimide and tertiary butyl hydroquinone (12.1% each), in descending order of frequency. Hence, patch testing, with the standard series supplemented by personal cosmetics; should be considered for patients with cosmetic dermatitis to determine the offending allergen so as to avoid further contact with that allergen.

Klippel-Trenaunay syndrome with a life-threatening thromboembolic event

Klippel‐Trenaunay syndrome is a congenital disorder characterised by the triad of cutaneous vascular nevi, soft tissue or bony hypertrophy, and varicose veins or venous malformations involving one or more extremities. An incidence of venous thromboembolism of up to 22% has been reported in this disorder. Also reported but rare is the development of trophic changes. Herein, we report the case of a male with Klippel‐Trenaunay syndrome, deep vein thrombosis, venous ulceration, and death due to recurrent pulmonary embolism.

Enhanced response of childhood psoriasis to narrow-band UV-B phototherapy with preirradiation use of mineral oil.

Abstract:  Studies in adults show that pretreatment with an optimal emollient may improve transmission of ultraviolet‐B. In our study, we evaluated whether the preirradiation use of mineral oil enhanced the efficacy of narrow‐band ultraviolet‐B phototherapy in childhood psoriasis. Twenty children, aged 5 to 14 years with widespread, symmetrical psoriasis involving >20% body surface area were enrolled in a prospective, single‐blind, controlled study. Mineral oil was applied prior to irradiation over one half of the body and the other half was emollient‐free control. Narrow‐band ultraviolet‐B phototherapy was administered to whole body twice a week on nonconsecutive days with initial dose of 50 mJ/cm2 and increment of 10% at each session. Clinical response was evaluated as grades of erythema, scaling and induration, area of involvement and modified psoriasis area severity index score on each side at baseline, 3, 6, 9, and 12 weeks. Two patients dropped out, 18 patients completed the study. Significantly greater improvement (p < 0.05) in scaling, induration, area of involvement, and modified psoriasis area severity index score was seen on the mineral oil pretreated side as early as 3 weeks and was maintained throughout the study. Difference in erythema was noticed later at 6 weeks. The cumulative dose for clearance was significantly lower on the emollient pretreated side. No adverse effects were observed with mineral oil or narrow‐band ultraviolet‐B phototherapy. We conclude that preirradiation use of mineral oil enhances the therapeutic efficacy of narrow‐band ultraviolet‐B phototherapy in children with widespread psoriasis.

Role of contact allergens in pompholyx.

Fifty patients of both sexes with clinically suspected pompholyx were patch tested with the Indian Standard Patch Test Battery approved by the Contact & Occupational Dermatosis Forum of India (CODFI). Most of these patients were young adults between 20–39 years of age with a mean age of 30 years. The mean duration of symptoms was 4 years. The occupational profile of the patients included students (20%), housewives (16%), housewives engaged in farming (12%), labourers (12%), farmers (12%) and paramedical workers (6%). The miscellaneous group, including salesmen, teachers and photographers, accounted for the remaining 22%. The clinical patterns of presentation of pompholyx included cheiropompholyx (60%), cheiropompholyx and podopompholyx (36%) and podopompholyx alone (4%). Patch test analysis of these patients revealed that, out of the 50 subjects tested, 20 (40%) reacted to one or more allergens. Nickel sulphate was the commonest offending allergen (14%) followed by potassium dichromate and phenylene diamine and nitrofurazone (8% each), fragrance mix (6%) and cobalt chloride (4%), in descending order of frequency. Hence, patch testing may be considered for all patients with recurrent episodes of pompholyx as allergic contact dermatitis may be relatively common in such patients and the avoidance of offending allergens may be of substantial benefit to these patients.

Tuberculosis verrucosa cutis presenting as diffuse plantar keratoderma: an unusual sight.

Tuberculosis verrucosa cutis (TVC) is a common cutaneous form of paucibacillary tuberculosis in an individual with moderate to high degree of immunity to Mycobacterium tuberculosis infection. Clinical appearance of TVC is mostly very typical with well-defined warty plaques presenting mostly on hands, knees, ankle, and buttocks; however several atypical morphology of the lesions have also been described. We hereby report a case of TVC, masquerading as asymptomatic diffuse keratoderma of left foot for nine months, in an otherwise healthy individual, obstructing easy diagnosis of cutaneous tuberculosis. Diagnosis was confirmed by histopathology.

Profiling and hormonal therapy for acne in women

Acne vulgaris is the most common condition treated by physicians worldwide. Though most acne patients remit spontaneously, for the ones that do not or are unresponsive to conventional therapy or have obvious cutaneous signs of hyperandrogenism, hormonal therapy is the next option in the therapeutic ladder. It is not strictly indicated for only those patients who have cutaneous or biochemical evidence of hyperandrogenism, but can be used even without any evidence of hyperandrogenism, for therapy-resistant acne. It can be prescribed as monotherapy, but when used in combination with other conventional therapies, it may prove to be more beneficial. Hormonal evaluation is a prerequisite for hormonal therapy, to identify the cause behind hyperandrogenism, which may be ovarian or adrenal. This article reviews guidelines for patient selection and the various available hormonal therapeutic options, their side-effect profile, indications and contraindications, and various other practical aspects, to encourage dermatologists to become comfortable prescribing them.

Trichophyton rubrum onychomycosis in a 10-week-old infant

dry eye syndrome. Skin changes in the neonate are marked by generalized erythema. At times, the skin is leathery with diffuse scales. Erythrokeratoderma develops during infancy. Erythematous, nonscaling, verrucous plaques are characteristically located on the forehead, cheeks, perioral area, elbows, knees, and scalp. Linear and spiny hyperkeratoses of the flexures, ichthyosis hystrix-like scaling of the limbs, diffuse truncal follicular hyperkeratosis, palmoplantar hyperkeratosis, teeth anomalies, nail dystrophy, sparse eyelashes and eyebrows, and alopeciamaybe seen. Primarily, sensorineural deafness, usually congenital in onset, with varying severity is always present. The hearing loss acts as an impediment to the development of normal vocalization. Few other associations of KID syndrome are known. Two cases with Dandy–Walker malformation and one with an enlarged cisterna magna have been reported. Miteva reported a child with bilateral lacrimal punctal agenesis who also had bilateral amastia. The present report is the first to describe a cardiovascular association, namely perimembranous VSD, in KID syndrome.

Hypertrophic lupus vulgaris: an unusual presentation.

Lupus vulgaris is the most common form of cutaneous tuberculosis occurring in previously sensitized individuals with a high degree of tuberculin sensitivity. Various forms including plaque, ulcerative, hypertrophic, vegetative, papular, and nodular forms have been described. A 30-year-old male patient presented with a very large hypertrophic lupus vulgaris lesion over left side of chest since 22 years. Histopathological examination showed granulomatous infiltration without caseation necrosis. The Mantoux reaction was strongly positive. Hypertrophic lupus vulgaris of such a giant size and that too at an unusual site is extremely rare and hence is being reported.

Clouston syndrome associated with severe congenital pseudo-ainhum.

2003:785–808. 7. Daley TD. Intraoral sebaceous hyperplasia. Diagnostic criteria. Oral Surg OralMedOral Pathol 1993;75:343–347. 8. Ortiz-Rey JA, Martin-Jimenez A, Alvarez C et al. Sebaceous gland hyperplasia of the vulva. Obstet Gynecol 2002;99:919–921. 9. Luba MC, Bangs SA, Mohler AM et al. Common benign skin tumors. Am Fam Physician 2003;67:729–738. 10. Boschnakow A, May T, Assaf C et al. Ciclosporin A-induced sebaceous gland hyperplasia. Br J Dermatol 2003;149:198–200.