Manas Chatterjee

Topical corticosteroid abuse on the face: A prospective, multicenter study of dermatology outpatients

BACKGROUND Abuse of topical corticosteroids (TC), especially over the face, is prevalent worldwide, including in India. Data about the magnitude of this problem in our country is lacking. AIMS The aims of this study were to ascertain the demographics, magnitude and clinical features of TC misuse on the face in the dermatology outpatient department (OPD) attendees in order to raise awareness about this problem and to analyze its causes. METHODS This was a prospective multicenter questionnaire-based clinical study conducted at 12 dermatology centers nationwide. Patients with relevant facial dermatoses reporting to the investigator were asked about their current use of over-the-counter topical formulations and a structured questionnaire applied in case the same was confirmed to be TC. RESULTS A total of 2926 patients with facial dermatoses were screened, of which 433 (14.8%) were using TC. TC was used as a fairness/general purpose cream or aftershave in 126 (29%) and in 104 (24%) for acne. Steroid combinations were used by 258 (59.6%). Potent and super-potent TC were significantly (P = 0.05) more frequently used by the rural/suburban population. The younger age groups used more potent formulations. A non-physician recommendation for TC use was obtainable in 257 (59.3%) patients. Of these, 232 (90.3%) were for potent/super-potent steroids. Among 176 physician prescriptions, 78 (44.3%) were from non-dermatologists. All non-physician prescriptions and 146 (83%) physician prescriptions for TC were inappropriately refilled. Adverse effects were seen in 392 (90.5%) TC users. Acne/exacerbation of acne was the most common adverse effect. CONCLUSIONS TC misuse in patients with facial dermatoses is quite common, and most of this use is unwarranted. Use as a fairness cream is the most common indication in this cohort. LIMITATIONS This was an OPD-based study and, therefore, it may or may not accurately reflect the community data.

Cyclosporine in Stevens Johnson syndrome and toxic epidermal necrolysis and retrospective comparison with systemic corticosteroid

BACKGROUND Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening dermatological emergencies. Many immunosuppressive modalities have been tried with variable results. AIMS To determine the efficacy of cyclosporine in cases of SJS and TEN and compare the efficacy with systemic corticosteroid in the same condition. METHODS Study was conducted at a tertiary hospital during 01 July 2011 to 30 June 2012. SCORTEN was assessed at the time of admission. Total body surface area (TBSA) assessment was like any burn patients. Cyclosporine was administered in the dose of 3 mg/kg body weight in three divided dosage for 07 days and then tapered over another 07 days. Data were compared to a historical series of SJS/TEN patients, managed by systemic steroids a year ago. RESULTS A total of 11 consecutive patients with a mean age of 32.09 and standard deviation (SD 16.17) were enrolled in to cyclosporine group, which were retrospectively compared to 6 patients with a mean age of 27.87 (SD 13.97) years in the corticosteroid group. The mean duration of re-epithelialization was 14.54 (SD 4.08) and 23 days (SD 6.68) in cyclosporine and corticosteroid group respectively (P = 0.009956). Mean hospital stay was 18.09 (SD 5.02) and 26 (SD 6.48) days in cyclosporine and corticosteroid group respectively (P = 0.02597). A total of 1.11 and 0.51 patients were expected to die against no death and two deaths in cyclosporine and corticosteroid group respectively (Standardized mortality ratio = 3.92) (P = 0.04321). CONCLUSION This study definitely suggests that cyclosporine has encouraging role in the management of uncomplicated cases of SJS, SJS-TEN overlap or TEN.

Lyme borreliosis and skin.

Lyme disease is a multisystem illness which is caused by the strains of spirochete Borrelia burgdorferi sensu lato and transmitted by the tick, Ixodes. Though very commonly reported from the temperate regions of the world, the incidence has increased worldwide due to increasing travel and changing habitats of the vector. Few cases have been reported from the Indian subcontinent too. Skin manifestations are the earliest to occur, and diagnosing these lesions followed by appropriate treatment, can prevent complications of the disease, which are mainly neurological. The three main dermatological manifestations are erythema chronicum migrans, borrelial lymphocytoma and acrodermatitis chronica atrophicans. Many other dermatological conditions including morphea, lichen sclerosus and lately B cell lymphoma, have been attributed to the disease. Immunofluorescence and polymerase reaction tests have been developed to overcome the problems for diagnosis. Culture methods are also used for diagnosis. Treatment with Doxycycline is the mainstay of management, though prevention is of utmost importance. Vaccines against the condition are still not very successful. Hence, the importance of recognising the cutaneous manifestations early, to prevent systemic complications which can occur if left untreated, can be understood. This review highlights the cutaneous manifestations of Lyme borreliosis and its management.

Role of NF-κB in the pathogenesis of psoriasis elucidated by its staining in skin biopsy specimens.

NF‐κB is a transcription factor belonging to the Re1 family, and it regulates the activity of a large number of proinflammatory genes. Its role in psoriasis, which is a prototype chronic inflammatory disease, is therefore expected to be considerable. It has been found that many of the triggering factors for psoriasis initiate inflammation by activation of NF‐κB.

Extramammary Paget's disease

Two patients with extramammary Pagets disease are being reported. The first case was a 60-year-old male who presented with gradually progressive pruritic ulcerated lesion over perianal region not responding to various topical medications. Dermatological examination revealed a large erythematous sharply marginated scaly plaque in the perianal region extending into the anal canal, covered with grayish crusts and shallow erosions. Skin biopsy from the lesion was suggestive of Pagets disease. The second patient, a 60-year-old male, with a three year long history, presented with similar lesions and findings. Skin biopsy in this case was also consistent with Pagets disease. These two cases of extramammary Pagets disease involving the perianal region are being reported because of their rarity and also to stress the fact that a high degree of suspicion is needed for the diagnosis of this uncommon disease entity.

A comparative study of efficacy of cultured versus non cultured melanocyte transfer in the management of stable vitiligo

BACKGROUND Replenishing melanocytes by autologous melanocytes selectively in vitiliginous macules is a novel and promising treatment. With expertise in culturing autologous melanocytes, it has now become possible to treat larger recipient areas with smaller skin samples. To determine the relative efficacy of cultured versus non cultured melanocyte transfer in the management of stable vitiligo. METHODS The melanocytes were harvested as an autologous melanocyte rich cell suspension from a donor split thickness graft. Cultured or non cultured melanocytes were then transplanted to the recipient area that had been superficially dermabraded. 100 patches of vitiligo in patients reporting to this hospital were randomly allocated into 2 groups to receive either of the interventions. RESULTS An excellent response was seen in 62.17% cases with the autologous melanocyte rich cell suspension technique and in 52% with the melanocyte culture technique. CONCLUSION Autologous melanocyte transplantation can be an effective form of surgical treatment in stable but recalcitrant lesions of vitiligo. Large areas of skin can be covered with a smaller donor skin using melanocyte culture technique; however culture method is more time consuming, and a labour intensive process, requiring state of the art equipments with a sterile lab setup.

Surgical Outcome in Patients Taking Concomitant or Recent Intake of Oral Isotretinoin: A Multicentric Study-ISO-AIMS Study.

Background: The current standard recommendation is to avoid surgical interventions in patients taking oral isotretinoin. However, this recommendation has been questioned in several recent publications. Aim: To document the safety of cosmetic and surgical interventions, among patients receiving or recently received oral isotretinoin. Materials and Methods: Association of Cutaneous Surgeons, India, in May 2012, initiated this study, at 11 centers in different parts of India. The data of 183 cases were collected monthly, from June 2012 to May 2013. Of these 61 patients had stopped oral isotretinoin before surgery and 122 were concomitantly taking oral isotretinoin during the study period. In these 183 patients, a total of 504 interventions were performed. These included[1] 246 sessions of chemical peels such as glycolic acid, salicylic acid, trichloroacetic acid, and combination peels;[2] 158 sessions of lasers such as ablative fractional laser resurfacing with erbium-doped yttrium aluminum garnet and CO2, conventional full face CO2laser resurfacing, laser-assisted hair reduction with long-pulsed neodymium-doped yttrium aluminum garnet, diode laser, and LASIK surgery;[3] 27 sessions of cold steel surgeries such as microneedling, skin biopsy, subcision, punch elevation of scars, excision of skin lesion, and wisdom tooth extraction;[4] 1 session of electrosurgery. Results: No significant side effects were noted in most patients. 2 cases of keloid were documented which amounted to 0.4% of side effects in 504 interventions, with a significant P value of 0.000. Reversible transient side effects were erythema in 10 interventions and hyperpigmentation in 15. Conclusion: The study showed that performing dermatosurgical and laser procedures in patients receiving or recently received isotretinoin is safe, and the current guidelines of avoiding dermatosurgical and laser interventions in such patients taking isotretinoin need to be revised.

Incidence and care of environmental dermatoses in the high-altitude region of Ladakh, India.

Background: Low humidity, high-velocity wind, excessive ultraviolet (UV) exposure, and extreme cold temperature are the main causes of various types of environmental dermatoses in high altitudes. Materials and Methods: A retrospective study was carried out in patients visiting the lone dermatology department in Ladakh between July 2009 and June 2010. The aim was to identify the common environmental dermatoses in high altitudes so that they can be treated easily or prevented. The patients were divided into three demographic groups, namely, lowlanders, Ladakhis (native highlanders), and tourists. Data was analyzed in a tabulated fashion. Results: A total of 1,567 patients with skin ailments were seen, of whom 965 were lowlanders, 512 native Ladakhis, and 90 were tourists. The skin disorders due to UV rays, dry skin, and papular urticaria were common among all groups. The frequency of melasma (n = 42; 49.4%), chronic actinic dermatitis (CAD) (n = 18; 81.81% of total CAD cases), and actinic cheilitis (n = 3; 100%) was much higher among the native Ladakhis. The frequency of cold-related injuries was much lesser among Ladakhis (n = 1; 1.19%) than lowlanders (n = 70; 83.33%) and tourists (n = 13; 15.47%) (P < 0.05). Conclusion: Dryness of skin, tanning, acute or chronic sunburn, polymorphic light reaction, CAD, insect bite reactions, chilblain, and frostbite are common environmental dermatoses of high altitudes. Avoidance of frequent application of soap, application of adequate and suitable emollient, use of effective sunscreen, and wearing of protective clothing are important guidelines for skin care in this region.

A Study of Various Histopathological Features and their Relevance in Pathogenesis of Psoriasis.

Background: The pathogenesis of psoriasis is still to be fully unraveled. The immunological theory with T cells at the centre of attraction and peripherally acting cytokines are the present favourites among aetiopathological factors. Histopathology of the skin lesions offers a good study model to understand the pathogenesis of this complex disease. Aims: To study the various histopathological parameters of psoriatic lesions, and to establish their correlation with the pathogenesis of the disorder. Materials and Methods: Eighty eight consecutive histopathologically proven cases of psoriasis were included in the study. Eight common histopathological parameters of psoriasis present in these biopsies were assessed and graded. We then statistically analyzed the relationship of the factors with one another and attempted to establish a better understanding of the pathogenesis of disease. Results: Significant correlations were found between degree of epidermal hyperplasia and inflammatory infiltrate, grade of inflammation and pustules of Kogoj, inflammatory infiltrate and grade of capillary proliferation as also between epidermal hyperplasia and the presence of parakeratosis. Conclusion: The study suggests that the immunopathogenesis of psoriasis is predominantly based on the inflammatory response. This is in consonance with other studies which have suggested that psoriasis is primarily a T lymphocyte based disease. Several treatment modalities are now based on this concept and it is hoped that the future treatment modalities will focus on the central role of inflammatory cells in the pathogenesis of this enigmatic disease.

Nano-silver dressing in toxic epidermal necrolysis

and systemic methotrexate were previously tried in that patient with no improvement.3 Iontophoresis utilizing methotrexate and cyclosporine A has been assessed in animal models and experimental studies but there have been only two reports that utilized iontophoresis with therapeutic drugs to manage psoriasis.4,5 The first was a case report where palmar psoriasis was successfully managed utilizing methotrexate iontophoresis and the second was a retrospective study of 31 patients where dexamethasone iontophoresis was used for treating nail psoriasis.6,7 Although there was a satisfactory improvement in psoriatic lesions, none of these reports mention the duration of remission.