Kaushal K. Verma

Intralesional immunotherapy with killed Mycobacterium w vaccine for the treatment of ano‐genital warts: an open label pilot study

Background  Intralesional immunotherapy with skin test antigens and vaccines has been found to be effective in the management of genital and extragenital warts.

THE FREQUENCY OF SEXUAL DYSFUNCTIONS IN PATIENTS ATTENDING A SEX THERAPY CLINIC IN NORTH INDIA

Analyzed data on 1000 consecutive patients with sexual disorders attending the psychosexual clinic at the All India Institute of Medical Sciences. The majority of patients were educated males between 21 and 30 years of age, belonging to the middle class. There was a slight preponderance of married patients. Fifty-two percent of patients had premarital or extramarital sexual contact; less than 5% had had homosexual contact; 10% had no sexual contact. Most patients had more than one complaint. Premature ejaculation (77.6%) and nocturnal emission (71.3%) were the most frequent problems followed by a feeling of guilt about masturbation (33.4%) and small size of the penis (30%). Erectile dysfunction was a complaint of 23.6%. Excessive worry about nocturnal emission, abnormal sensations in the genitals, and venereophobia was reported in 19.5, 13.6, and 13% of patients, respectively. Only 36 female patients attended the clinic with their spouses.

A two-step schedule for the treatment of actinomycotic mycetomas.

Actinomycotic mycetomas usually respond slowly to treatment with antibiotics. In an attempt to hasten clinical resolution, we used a 2-step regimen consisting of an intensive phase of therapy with penicillin, gentamycin and co-trimoxazole for 5-7 weeks, followed by maintenance therapy with amoxicillin and co-trimoxazole. Seven patients were treated, all of whom showed significant reduction in discharge and swelling after the intensive phase. Maintenance therapy was continued for 2-5 months after the lesions became completely inactive. Five patients completed maintenance therapy, which was given for 6-16 months (mean 10.7 months), and remained free of disease during a mean post-treatment follow-up period of 6.4 months. The other 2 patients also responded satisfactorily and continue to receive maintenance therapy. Side-effects necessitating a modification of the treatment schedule occurred in 2 patients but reversed on discontinuation of the drugs responsible. This treatment schedule produces a rapid clinical response during the initial, intensive phase and promotes compliance with the longer maintenance phase of treatment necessary to achieve a complete cure.

Total skin electron irradiation therapy in mycosis fungoides using high-dose rate mode: A preliminary experience

Introduction  Total skin electron irradiation (TSEI) therapy is the treatment of choice for mycosis fungoides. However, conventional TSEI therapy is time consuming as well as patient unfriendly. Therefore we used high‐dose rate (HDR) mode TSEI in these patients. High‐dose rate mode of TSEI is a technological innovation attached to a Linear Accelerator (Philips, SL‐20, Netherlands), which can deliver an electron beam of 30 Gy/min at the iso‐center. The iso‐center faces the patient, 100 cm away from the target of the linear accelerator. The patient is treated at a distance of 10 feet from the iso‐center of the linear accelerator. The dose delivered to the skin was 1.13 Gy/min, making the treatment execution much easier and patient compliance much better.

Diaper dermatitis--an overview.

Diaper dermatitis, also know as nappy rash, is an inflammation of the skin covered by nappy. It probably results due to an interaction of multiple factors like increased wetness, elevated pH due to urine, fecal enzymes and microorganisms under the nappy. It manifests as an erythematous rash occurring on the convex surfaces of skin under the nappy. Rashes resembling nappy dermatitis can also be caused by some diseases which may have serious systemic manifestations. Therefore it is essential to differentiate and treat them. The principle of treatment of diaper dermatitis is to keep the skin in the nappy area as dry as possible with frequent nappy change. The superabsorbent disposable diapers are known to reduce the incidence of diaper dermatitis. Barrier creams to protect the infant’s skin and mild topical corticosteroids to reduce the inflammation are mainstays of therapy. The incidence and severity can be reduced by keeping the skin dry under the nappy and protected from irritants and infections.

Azathioprine as a Corticosteroid Sparing Agent for the Treatment of Dermatitis Caused by the Weed Parthenium

Air-borne contact dermatitis caused by Parthenium hysterophorus is a serious problem in India. Patients with this condition have to use corticosteroids regularly in order to maintain clinical remissions, but prolonged usage causes serious side-effects. The weed cannot be eradicated. We have used 3 therapeutic regimens with azathioprine, which led to an effective control with minimal side-effects even when used for long periods. A total of 22 patients (group I) were given 50 mg azathioprine twice a day; 11 patients (group II) received 50 mg azathioprine per day and 300 mg azathioprine every 28 days, and 10 patients (group III) were given 50 mg azathioprine twice a day along with 300 mg azathioprine every 28 days. The duration of treatment varied from 6 months to 3 years. Twenty patients in group I and 9 patients each in groups II and III had complete remission. Nine, 7 and 6 patients in the respective groups needed additional oral betamethasone 1-2 mg per day for brief periods only during the peak season in order to maintain complete remission. One patient in each group had only partial relief. The need for oral betamethasone during the second and the third year was further reduced. One patient each in group I and group II could not continue azathioprine due to the side-effects of the drug.

Parthenium dermatitis treated with azathioprine weekly pulse doses

BACKGROUND Parthenium dermatitis is a serious problem in India. Corticosteroids are the mainstay of treatment but the prolonged use of corticosteroids can cause serious side effects. Azathioprine used in daily doses has been shown to be effective. AIM We have evaluated the effectiveness of azathioprine weekly pulse doses for the treatment of parthenium dermatitis. METHODS Twelve patients, ten males and two females, aged between 39 and 65 years (mean +/- SD = 53.5 +/- 8.7) having air-borne contact dermatitis to Parthenium hysterophorus for 3-19 years (mean = 6.33) were included in the study. The diagnosis in each patient was confirmed by patch-testing. The severity of the disease was determined by clinical severity score (CSS) on the basis of erythema, itching, type of lesions, and areas of body involved. RESULTS The pretreatment CSS in these patients varied from 29.7 to 55.5 (mean +/- SD: 40.40 +/- 7.95). After clinical and laboratory evaluation, the patients were treated with 300-mg azathioprine once-weekly doses for 6 months. Clinical and laboratory evaluations were repeated at weeks 1, 2, and then every 4 weeks until the end of therapy to evaluate the therapeutic response and side effects. The response was excellent (80-100% clearance of disease) in seven (58.33%) patients and good (60% clearance) in five (41.66%) patients. The post-treatment CSS decreased from the mean +/- SD of 40.4 +/- 7.95 to 10.9 +/- 8.43 (P = 0.002). There were no significant side effects of the therapy. CONCLUSIONS In this preliminary open study, azathioprine in weekly pulse doses has been found to be effective without any serious adverse effects in the treatment of parthenium dermatitis. The cost of therapy with this regimen is reduced by 60%.

Parthenium dermatitis presenting as photosensitive lichenoid eruption. A new clinical variant.

Parthenium hysterophorus is the commonest cause of airborne contact dermatitis (ABCD) in India. The disease usually manifests as itchy erythematous, papular, papulovesicular and plaque lesions on exposed areas of the body. Rarely, however, the disease may present as actinic reticuloid or photocontact dermatitis. We have observed a different clinical variant of this disease where certain patients with Parthenium dermatitis have presented with discrete, flat, violaceous papules and plaques on exposed areas of the body closely simulating photosensitive lichenoid eruption. We had 8 patients, 6 males and 2 females between 30 and 62 years of age, with itchy, violaceous, papules and plaques on the face, neck, ears, upper chest and dorsa of the hands for 6 months to 6.5 years. Four of these patients had a history of improvement of the lesions up to 30% in winter and aggravation of lesions on exposure to sunlight. There was no personal or family history of atopy. Cutaneous examination in all patients revealed multiple flat, violaceous, mildly erythematous papules and plaques on the forehead, sides and nape of neck, ears, ‘V’ area of the chest, and extensor aspects of the forearms and hands. Skin biopsies from these lesions showed features of chronic non‐specific dermatitis. Patch testing with standardized plant antigens showed a positive patch test reaction to Parthenium hysterophorus in all patients, with a titre of contact hypersensitivity (TCH) varying from undiluted to 1 : 100. We conclude that Parthenium dermatitis may occasionally present with lesions very similar to the lesions of photosensitive lichenoid eruption in morphology and distribution. This clinical presentation of Parthenium dermatitis needs to be recognized to avoid misdiagnosis.

Intralesional Injection of Mycobacterium w Vaccine vs Imiquimod, 5%, Cream in Patients With Anogenital Warts: A Randomized Clinical Trial

IMPORTANCE Intralesional antigen therapy has been used in the treatment of anogenital warts (AGWs), but it has not been compared with existing therapies. Evidence of its efficacy is not strong. OBJECTIVE To compare the efficacy and safety of intralesional Mycobacterium w (Mw) vaccine with that of imiquimod, 5%, cream in the treatment of AGWs, as well as changes in human papillomavirus (HPV)-6 and HPV-11 viral loads. DESIGN, SETTING, AND PARTICIPANTS A double-blind randomized clinical trial was conducted in New Delhi, India, between February 2009 and July 2012 and included a 3-month follow-up. Of 159 patients with AGWs who were screened, 89 were randomized. INTERVENTIONS Patients received either imiquimod, 5%, cream and an intralesional vehicle (imiquimod group: 44 patients) or vehicle cream and intralesional Mw vaccine (Mw group: 45 patients). MAIN OUTCOMES AND MEASURES The primary end point was complete clinical remission of visible AGWs. Secondary measures included the percentage of reduction in the surface area of AGWs and viral load for HPV-6 and HPV-11. Viral load was measured by real-time quantitative polymerase chain reaction. RESULTS In the intention-to-treat analysis, 59% (n = 26) of the patients in the imiquimod group and 67% (n = 30) of those in the Mw group had complete resolution (P = .52). Eighteen HPV genotypes, including high-risk genotypes, were detected, with no significant differences between the treatment groups (all P > .05). There was a significant decline in the mean viral loads of HPV-6 (from 0.011 × 108 to 0.00000154 × 108 copies/mg of tissue; P = .003) and HPV-11 (from 0.121 × 108 to 0.017 × 108 copies/mg of tissue; P = .03) after treatment in the Mw group but only in the viral load of HPV-6 (from 1.41 × 108 to 0.004 × 108 copies/mg of tissue; P = .01) in the imiquimod group. There was no recurrence of AGWs in patients with complete clearance at the 3-month follow-up and no serious adverse events. CONCLUSIONS AND RELEVANCE Imiquimod, 5%, and the Mw vaccine were equally effective in achieving clinical and virologic clearance for HPV-6. A significant decline in the HPV-11 viral load was achieved only with the Mw vaccine. Efficacy and safety of intralesional Mw vaccine is comparable to that of imiquimod, 5%, in treatment of AGWs. TRIAL REGISTRATION ctri.nic.in Identifier: CTRI/2009/091/000055.

Azathioprine versus betamethasone for the treatment of parthenium dermatitis: a randomized controlled study.

BACKGROUND Parthenium hysterophorus is the commonest cause of airborne contact dermatitis in India. Azathioprine has been shown to be effective and safe in parthenium dermatitis, but there are no reports of comparison of steroids and azathioprine in this condition. AIMS To study the therapeutic efficacy of azathioprine versus betamethasone in patients having contact dermatitis to parthenium and compare the side effects of the drugs. METHODS Fifty-five patients of airborne contact dermatitis to parthenium were randomly assigned to treatment with azathioprine 100 mg daily (group A) or betamethasone 2 mg daily (group B), for 6 months in a blinded manner. The patients were evaluated every month for 6 months to determine the response to treatment and side effects and then further followed up for another 6 months to determine any relapse. RESULTS There were 26 patients in group A and 29 in group B, of which 20 patients of group A and 21 of group B completed the study. Nineteen (95%) patients in group A and all 21 (100%) patients in group B had an excellent response (complete remission) to treatment (P=0.0156 vs. 0.0005). The patients in group B, however, had more adverse effects (Fisher exact, P<or=0.05). Nine (45%) patients in group A and 14 (67%) patients in group B relapsed during the post-treatment follow-up. CONCLUSIONS Azathioprine and betamethasone appear to be almost equally effective (P=0.0156 vs. 0.0005) in the treatment of parthenium dermatitis. However, adverse effects and relapses were observed to be more frequent in patients treated with betamethasone.