Murlidhar Rajagopalan

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.

Fixed drug eruption due to tinidazole with cross-reactivity with metronidazole

A.J. Kanwar, MD, Rajeev Sharma, MD, Murlidhar Rajagopalan, MD, Surrinder Kaur, MD, FAMS, Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh (India) Sir. A large number of drugs are capable of producing fixed drug eruptions [1]. The list has ever been on the increase. A case of fixed drug eruption due to tinidazole is being reported. There was a cross-sensitivity with metronidazole. Case Report. A 32-year-old male patient was examined for a persistent hyperpigmented area over the left buttock of 2 months’ duration. Initially it had appeared as an erythematous patch following ingestion of Fasigyn (tinidazole) prescribed for giardiasis. The erythema and the accompanying burning gradually subsided over a period of 5-6 days leaving behind the pigmented patch. There was no history of exacerbation of the lesion following ingestion of any other drug. Examination revealed a slate-grey, 4 by 3 cm plaque over the left buttock. A ciiagnosis of fixed drug eruption was made and the patient subjected to provocation tests as detailed by Pasricha [2], with the following drugs: acetylsalicylic acid, paracetamol, co-trimoxazole, phe-nobarbitone, sulphadiazine, phenolphthalein, tetracycline and eryth-romycin. None of these drugs produced any activation of the lesion. Then Fasigyn (tinidazole) 500 mg was given as the challenging dose and in about 6 h the patient developed severe itching and marked erythema at the site of lesion on the buttock. Topical corticosteroids were prescribed and after the activity had subsided, the patient was given one tablet of Flagy 1 (metronidazole) 200 mg. Within 4 h of taking this drug ‚ he again developed severe itching and intense erythema on the lesion over the buttock. Comments. Tinidazole is being widely used in the treatment of giardiasis, amebiasis, trichomoniasis and anaerobic bacterial infections. Reported side effects pertain chiefly to the gastrointestinal system. Apart from report of an allergic skin reaction due to tinidazole in 1 patient in a multicenter study [3], there have been no reports of any adverse cutaneous reactions due to this drug. Reappearance of lesion in response to a challenging dose of tinidazole confirms that the fixed eruption was caused by this drug. The patient also showed a cross-reactivity with metronidazole. Tinidazole has close, structural resemblance to metronidazole (fig.l). It differs from metronidazole in having an ethyl group at position 2. There have been only two instances of fixed drug eruptions due to metronidazole [4,5]. The purpose of this report is to alert the physician

Consensus statement on the management of urticaria.

This consensus statement was developed by Special Interest Group – Urticaria (IADVL). Urticaria, a heterogeneous group of diseases, often cannot be recognized by its morphology. Due to non-specific and non-affordable diagnosis, management of urticaria, especially chronic urticaria, is very challenging. This guideline includes definition, causes, classification and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is identification and elimination of the underlying cause(s) and/or eliciting trigger(s), while the second one is treatment aimed at providing symptomatic relief. This guideline recommends use of second-generation non-sedating H1 antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the cost.

Consensus statement for the diagnosis and treatment of urticaria: A 2017 update

This article is developed by the Skin Allergy Research Society of India for an updated evidence-based consensus statement for the management of urticaria, with a special reference to the Indian context. This guideline includes updated definition, causes, classification, and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is by identification and elimination of the underlying cause(s) and/or eliciting trigger(s) while the second one is by treatment for providing symptomatic relief. This guideline recommends the use of second-generation nonsedating H1-antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the associated medical condition, severity of the symptoms, affordability of the drugs, and accessibility of modern biologics such as omalizumab.

Biologics use in Indian psoriasis patients

The biologics currently in use for psoriasis in India are etanercept, infliximab and recently introduced itolizumab and secukinumab. Biosimilars, expected to play a significant role in psoriasis management in future, have also been available for the last few years. Patients with psoriasis may be considered eligible to receive treatment with any of the licensed biologic interventions when they fulfill the eligibility criteria. The decision to proceed with treatment must be made in collaboration with the patient and include a careful assessment of the associated risks and benefits. Etanercept is indicated in moderate to severe psoriasis and moderate to severe psoriatic arthritis with a dose of 25 mg or 50 mg twice weekly. Methotrexate may be recommended as co-medication in certain clinical circumstances, e.g., where it is required for associated arthropathy, or to improve efficacy. Infliximab is indicated in severe psoriasis and moderate to severe psoriatic arthritis. Infliximab therapy should be initiated at a dose of 5 mg/kg at weeks 0, 2 and 6 and disease response assessed at 3 months.In patients who respond, subsequent infusions (5 mg/kg) should be given at 8-week intervals to maintain disease control although long-term data are available only up to 1 year.Interrupted therapy should be avoided given the associated increased risk of infusion reactions and poorer disease control. Itolizumab is indicated in moderate to severe plaque psoriasis. It is given in a dose of 1.6mg/kg iv infusions every 2 weeks for 12 weeks initially and then 1.6mg/kg every 4 weeks up to 24 weeks. Long term data are unavailable. Secukinumab is indicated in moderate to severe plaque psoriasis and psoriatic arthritis.An initial loading dosing regimen of 300 mg secukinumab should be given by subcutaneous injection at weeks 0, 1, 2 and 3 followed by maintenance dose of 300 mg every 4 weeks starting at week 4. To exclude tuberculosis (TB) before anti TNF alfa therapy and therapy with itolizumab, pretreatment chest X-ray and Mantoux skin test currently remain the preferred screening tests in patients not on immunosuppression. During treatment, and for 6 months following discontinuation, a high index of suspicion for TB should be maintained. The effect of secukinumab on TB reactivation is as yet poorly understood, hence, in the Indian scenario, it is better to follow the same guidelines for ruling out latent TB

Position statement for the use of omalizumab in the management of chronic spontaneous urticaria in Indian patients.

Chronic spontaneous urticaria (CSU) affects 1% of the world population and also their quality of life, and 50% of these patients are refractory to H1-antihistamines. Omalizumab is a humanized monoclonal anti-IgE antibody that binds with free IgE antibodies and reduces the circulating levels of free IgE. This reduction in free IgE prevents mast-cell degranulation. The EAACI/GA2LEN/EDF/WAO guidelines recommend omalizumab as the third-line of therapy as an add-on to antihistamines. The recommended dose of omalizumab is 300 mg, 4 weekly in the management of CSU refractory to standard of care with H1-antihistamines in adults and adolescents ≥12 years of age. In some patients, a dose of 150 mg may be acceptable. Omalizumab has a good safety profile. However, due to the biologic nature of the drug, all patients administered omalizumab must be observed for 2 h after administration for anaphylactoid reactions. There have been no studies on the effect of impaired renal or hepatic function on the pharmacokinetics of omalizumab. While no particular dose adjustment is recommended, omalizumab should be administered with caution in these patients.

Diagnosis and management of chronic pruritus: An expert consensus review

The aim of this study is to formulate the best clinical practice in the diagnosis and management of chronic pruritus (CP). We searched PubMed, EMBASE, Scopus, Web of Science, and the WHOs regional databases, for studies on “Diagnosis and management of chronic pruritus” from January 1, 2014, to July 31, 2015. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data. We screened 87 of 95 studies that contained qualitative data. Avoid: Dry climate, heat, alcohol compress, ice packs, frequent bathing and washing, intake of very hot and spicy food, intake of alcohol, contact with irritant substances, excitement, strain and stress, and allergens. Using: Mild nonalkaline soaps, moisturizers, bathing oils, lukewarm water while bathing, soft cotton clothing and night creams/lotions, relaxation therapy, autogenic training, psychosocial education, educating patients to cope with itching and scratching, and educational programs. Especially use of moisturizers is considered important. In addition, symptomatic treatment options include systemic H1 antihistamines and topical corticosteroids. Symptomatic therapy directed toward the cause (hepatic, renal, atopic, polycythemia, etc.). If refractory or cause is unknown, consider capsaicin, calcineurin inhibitors for localized pruritus and naltrexone, pregabalin, ultraviolet therapy, Cyclosporine for generalized itching. CP is quite frequent finding associated with skin and systemic diseases in the overall population. It is known to significantly affect quality life score of an individual and also adds burden on the health-care cost. A specific recommendation for treatment of CP is difficult as a result of varied and diverse possibility of underlying diseases associated with CP.

The International Psoriasis Council Presents Top Five Psoriasis Research Articles for July 2010–December 2010

The International Psoriasis Council (IPC) is a global nonprofit organization dedicated to advancing psoriasis research and treatment by providing a forum for education, collaboration, and innovation among physicians, researchers, and other professionals interested in psoriasis. Each year, the IPC identifies the top papers in the field of psoriasis. Those selected from the second half of 2010 are reviewed here.