Kamaldeep Sandhu

Epidemiology of childhood psoriasis: a study of 419 patients from northern India.

Background  We undertook this study in order to determine the pattern and prevalence of childhood psoriasis in northern India and to highlight the differences and similarities with previous studies.

Efficacy and safety of cyclosporine versus methotrexate in severe psoriasis: a study from north India.

Treatment of patients with severe psoriasis is difficult. Among the number of systemic drugs that are available, methotrexate has long been used, but cyclosporine has been recently recommended for the management of severe psoriasis. The purpose of this study was to compare the efficacy and safety of daily cyclosporine with weekly methotrexate in the management of severe psoriasis. Thirty consecutive patients with severe psoriasis were randomly assigned to treatment with cyclosporine or methotrexate. The initial dose of cyclosporine was 3 mg/kg/day, which was increased to a maximum of 4 mg/kg after two weeks of therapy when the response was not adequate. Methotrexate was administered weekly at a dose of 0.5 mg/kg. Clinical response was assessed by calculating PASI score in all patients at biweekly intervals. Patients were followed up fortnightly up to a maximum of 12 weeks. The doses of both drugs were gradually tapered once >75% reduction in disease severity was attained. Marked improvement (>75%) reduction in PASI was noted in all patients except for one in the cyclosporine group. The median time for marked improvement was 5.3 weeks with methotrexate and 6.8 weeks with cyclosporine. Patients on methotrexate were found to have more rapid and complete clearance than those on cyclosporine. Both drugs were well tolerated. Side effects in both the treatment groups were minor, transient, and manageable. At doses with comparable safety profiles, methotrexate resulted in more rapid and cost effective clearance of patients with severe psoriasis. Cyclosporine can provide an effective and safe alternative.

The pattern of mucocutaneous infections and infestations in renal transplant recipients.

Immunosuppression‐related mucocutaneous lesions are a significant problem in renal transplant recipients. Infections account for the majority of these manifestations. The aim of this study was to determine the spectrum of mucocutaneous infections and infestations in renal transplant recipients. Over a period of three years, all the renal transplant recipients presenting with mucocutaneous lesions (only with infectious etiology) were included in the study. Diagnosis was based on the clinical appearance and appropriate investigations like scraping for KOH, Tzanck smear, cultures, and skin biopsies whenever necessary. In order to study the temporal effect of immunosuppression on these mucocutaneous infections, the patients were divided into six groups—with durations of graft survival ranging from 0–2, 2–6, 6–12, 12–24, 24–60, and more than 60 months in Groups A–F, respectively. A total of 104 renal transplant recipients presented with 117 infections and infestations. The mean age at presentation was 35.9 ± 1.2 years (15–65yrs), and the mean duration after the transplant was 23.3 ± 3.5 months (1–175). The mean serum creatinine level at the time of clinical presentation was 1.4 ± 0.07 mg/dl (0.7–6). Twenty‐seven patients were on a two‐drug regimen, prednisolone and azathioprine, and the rest were on a three‐drug regimen with cyclosporine in addition. Out of the total of 117 infections in 104 patients, 57 were viral, 49 were fungal, and 8 were bacterial. Two patients had scabies and one had cysticercosis. The mean time interval for the occurrence of infections after the transplant was earlier in patients on three‐drug immunosuppression (12.4 ± 2.3 months) than in those on the two‐drug regimen (51.3 ± 1.8 months), (p<0.01). The viral infections had the shortest mean time interval for presentation following transplant, 15.8 ± 1.2 months (p<0.05). We did not find any statistically significant difference with regard to age or sex of the patients, duration after the transplant, or the pattern of infection. Careful examination of transplant patients is essential for early detection and proper treatment, because the mucocutaneous infections can have atypical morphologies and are likely to become extensive if not treated early.

CUTANEOUS MASTOCYTOSIS IN CHILDREN: AN INDIAN EXPERIENCE

To the Editor: I read with great interest the article by Clifton et al (1) regarding immunotherapy of warts with mumps or Candida antigen. Cassone et al (2) used the term “microbial biological response modifier” to describe the immune modulatory effects of infectious microbes such as Candida albicans . They reported that Candida mannoprotein fragment F2 (MP-F2) is one of the strongest attractants of neutrophils. MP-F2, a powerful immunomodulatory fraction from the cell wall of C. albicans , is an active inducer of interleukin (IL)-8, tumor necrosis factor (TNF)α , IL-6, and IL-1 β production by human polymorphonuclear (PMN) cells and monocytes (2). Further, MacPhee et al (3) recovered CD4 + and CD8 +

Subdural Hygroma in a Patient with Parry-Romberg Syndrome

Abstract:  Parry‐Romberg syndrome (PRS) is a poorly understood disorder characterized by progressive hemifacial atrophy. A number of neurologic associations have been reported. We describe a rare association of seizures, PRS, and subdural hygroma. To the best of our knowledge, this association has not been reported in the literature.

Topical 0.25% methotrexate gel in a hydrogel base for palmoplantar psoriasis.

Palmoplantar psoriasis (PPP) is a chronic, disfiguring condition, and its management is difficult. The systemic side effects of methotrexate can be avoided if it is effective topically. We studied the efficacy and safety of a recently marketed topical methotrexate (0.25%) preparation in a hydrogel base in patients with palmoplantar lesions. A total of 14 adult patients diagnosed clinically as plaque type of palmoplantar psoriasis (>30% of the palm and/or sole areas involved) were included in the study. Topical methotrexate 0.25% in a hydroxygel base was applied twice daily to the lesions for twelve weeks. The lesions were assessed for degree of erythema, scaling, induration and fissuring (ESIF) and were scored on a severity score of 0–3 (0‐clear, 1‐mild, 2‐moderate, 3‐severe) every two weeks. The most severe condition was given 12 points; 0 denoted no disease. The response at the end of the study was graded as minimal if there was up to 25% reduction in the EISF score, mild as 26–50% reduction, moderate improvement as 51–75% reduction in score, and marked improvement as >75% reduction in score. The average age of the 11 male and female patients was 41.5 years (18–57 years) with the duration of the disease varying from 2 months to 15 years. Ten patients had both palmar and plantar lesions; two each had only palmar lesions or plantar lesions. The ESI score at baseline was 5.8 ± 0.9 for the palms and 6.8 ± 0.5 for the soles. The scores at the end of the study were 3.5 ± 0.7 for palms and 4.8 ± 0.2 for the soles. The average time taken for improvement was at least six weeks. None of the patients had complete clearance of lesions. The drug was well tolerated by all patients. Methotrexate 0.25% in a hydrophilic gel is well tolerated but is not very effective in controlling the lesions of psoriasis on the palms and soles. A higher concentration in a different base with better penetration could possibly provide better results.

Anhidrotic ectodermal dysplasia with palmoplantar keratoderma: an unusual presentation

Anhidrotic ectodermal dysplasia (AED), or Christ–Siemens–Touraine syndrome, was first described in 1848 by Thurnam. 1 It is characterized by a partial or complete absence of sweat glands, hypotrichosis and hypodontia. The mode of inheritance is predominantly X‐linked but an autosomal recessive pattern has also been observed. 2 Palmoplantar keratoderma is classically a component of hidrotic ectodermal dysplasia; 3 however, we report herein two brothers who had classical manifestations of AED along with palmoplantar keratoderma.

Sjögren-Larsson syndrome in an Indian child.

To the Editor: In the May/June 2003 issue, Pimentel et al (1) reported two children from Brazil with granular parakeratosis (GP), a rare dermatitis previously reported as occurring in the intertriginous areas of adults. Both children had been using Hipoglos pomade (Procter & Gamble do Brazil & Cia). The authors did not mention the fact that Hipoglos is a topical preparation consisting of vitamins A and D and zinc oxide. Granular parakeratosis has been reported in five other children less than 2 years of age. Each instance was associated with the topical application of zinc oxide paste (2) or Desitin (3), which contains zinc oxide. We recently evaluated an otherwise healthy 1-year-old boy with a 7-month history of pruritic, hyperkeratotic plaques in the groin bilaterally and around the penis. The patient had been treated with multiple topical preparations, including zinc oxide, pimecrolimus, tacrolimus, silver sulfadiazine, vinegar, nystatin, econazole, and triamcinolone. The differential diagnosis at presentation included irritant or contact dermatitis, psoriasis, dermatophyte infestation, acanthosis nigricans, and HaileyHailey disease. A specimen from a plaque showed the characteristic histopathologic changes of granular parakeratosis, including thick, compact basophilic parakeratosis without evidence of fungal elements with periodic acid-Schiff (PAS) staining. The boy’s mother was instructed to apply Vaseline and discontinue all other topical therapy, which resulted in gradual, complete resolution of the dermatitis without recurrence in 6 months of follow-up. Although an initial candidal or fungal infection cannot be entirely excluded, our patient’s presentation appears to be consistent with the previously reported conclusion that this is an unusual reaction to topical medicine and, perhaps more specifically, zinc oxide. One theory for the pathogenesis of GP involves a defect in the processing of profilaggrin to filaggrin, which maintains the keratohyaline granules in the stratum corneum (4,5). Jin et al (6) showed that zinc oxide applied topically to both incised and intact mouse skin significantly increased the mitotic index of the epidermal basal cells. The hyperkeratotic and acanthotic appearance of GP may be due in part to these same effects of topical zinc oxide on human skin. In addition to its proposed antimicrobial properties (7), increased proliferative activity of basal cells may be another reason for the enhanced wound healing seen with the topical application of zinc oxide pastes. Granular parakeratosis is likely an underreported reaction that should be considered in the differential diagnosis when children present with a hyperkeratotic dermatitis, particularly in the diaper area, where zinc oxide is often applied for various dermatoses.

Role of Pityrosporum ovale in guttate psoriasis.

Pityrosporum (malassezia) is a thick walled yeast, which inhabits superficial layers of the stratum corneum and forms part of the normal skin flora. Two main forms, Pityrosporum ovale (oval) and Pityrosporum orbiculare (round) are found in the chest, back and scalp, etc. The scalp is also a common site for psoriasis, and reports have suggested an association between P.ovale and the development of skin lesions. We report a patient who developed guttate lesions localized to the lesions of pityriasis versicolor. Case Report: A 67-year-old man presented with a one-month history of multiple, scattered, erythematous, scaly, papular lesions on his trunk and extremities. The patient also gave a history of another type of asymptomatic, minimally scaly, hypopigmented patches on the trunk and thighs for the previous 4–5 years. There was no history of similar lesions in the past. The patient was a known hypertensive who had been on enalapril for the last three years. Examination revealed large, geographic, mildly scaly, hypopigmented patches with scalloped borders over the back and thighs. Superimposed on these lesions were the fresher (one month duration), more prominent lesions, which were multiple, widely scattered, erythematous, scaly, papular lesions. These lesions were monomorphic and varied in size from 0.5–1 cm (Fig. 1). Auspitz sign was positive. A KOH preparation from the hypopigmented lesions showed short, wide fungal hyphae along with yeast cells (spaghetti and meatball appearance) on microscopy. Skin biopsy from the lesion revealed evidence of both fungal elements and psoriasis (Fig. 2). The patient was given fluconazole 150 mg/day orally for seven The Journal of Dermatology Vol. 30: 252–254, 2003

Localized hypertrichosis in subsiding psoriatic plaques

To the Editor: The sudden appearance of excessive hair growth in an abnormal site is not uncommon. Acquired localized hypertrichosis has been reported to occur after chronic mechanical or chemical trauma to a specific site (1–2). It is well known to occur in preexisting nevus and acquired melanocytic nevi (3). Psoriasis is a chronic inflammatory dermatosis that not only affects the skin but also the ectodermal structures like nails, hairs, and, rarely, mucous membranes (4). The hair involvement in psoriasis has not been studied in detail. Schuster first described reduced density of hair with dystrophic and telogen hair in psoriatic plaques (5). Scarring alopecia in psoriatic plaques with thinning of hair shafts and dystrophic changes on scanning electron microscopy has been described in the literature (6, 7). Hair loss from psoriatic plaques is well accepted; interestingly we report localized hypertrichosis occurring at the site of psoriatic plaques in two patients. Case Reports: Case 1: A 50-year-old male complained of excessive hair growth in few of his psoriatic lesions. He had had psoriasis vulgaris for the previous 10 years. The disease was mild with a body surface area of involvement <15%. The psoriatic lesions, which were, intensely pruritic, had partially improved after eight weeks of topical coal tar application. There was no history of use of steroids or any other systemic therapy in the past, because the lesions had always improved with coal tar therapy. Systemic examination was within normal limits. On cutaneous examination, three round to oral psoriatic lesions measuring 3 × 2 cm with discrete tufts of hair arising from them were distributed on the extensor aspect of the right forearm. His other psoriatic lesions did not reveal such changes. A biopsy taken from a lesion revealed mild psoriatic changes with normal hair structure and morphology. The majority of the hairs were in the anagen phase; there were no naevoid changes. Case 2: A 25-year-old male presented with a three-year history of psoriasis vulgaris. The lesions had started on the elbows and then spread to involve the lower legs. The patient had been treated topically with coal tar and calcipotriol. He denied use of topical steroids or any systemic therapy for the management of psoriasis. He had not noticed the lesional hypertrichosis, it was observed at the time of examination. On examination, there were three welldefined, erythematous, scaly, plaque lesions distributed on his right elbow and both shins. The lesion on the elbow measured 3 × 3 cm in size and had evident hypertrichosis. A biopsy taken from the lesion revealed psoriatic changes with no evidence of underlying nevus. Discussion: The hair changes associated with psoriasis described in the literature range from circumscribed alopecia, temporary hair loss, and abnormal trichogram to ultrastructural abnormalities (5–8). To the best of our knowledge, this is the first report of its kind in the literature. The exact explanation of the mechanism of localized hypertrichosis in psoriatic lesions is difficult to elucidate. The Journal of Dermatology Vol. 31: 693–695, 2004