Muthu Sendhil Kumaran

Pure neuritic leprosy in India: an appraisal

BACKGROUND Pure neuritic leprosy (PNL) constitutes a significant proportion of all cases in India, however, this form of disease has not been fully recognized and investigated and there is little information in the existing literature. OBJECTIVE To study the epidemiological characteristics of PNL in India. MATERIALS AND METHODS A retrospective analysis of leprosy clinic records for the period 1993 to 2003 was undertaken. Detailed demographic profiles and clinical findings were noted from the predesigned clinic proforma. A slit-skin smear for acid-fast baclli (AFB) was done in all cases from the area of sensory loss. A skin biopsy was done from the area of sensory impairment to study histopathological changes. Further investigations such as nerve conduction velocity studies (NCV), fine needle aspiration cytology (FNAC), or nerve biopsy (superficial nerve twigs) were done if indicated in patients whenever there was difficulty in clinical diagnosis. RESULTS Of the total 1542 leprosy patients seen over this period, 65 (4.2%) had PNL. Males were more commonly affected than females (2.6:1.). The majority of patients 40/65(61.5%) were aged between 15 and 35 yrs. Predominant presenting symptoms were paresthesia, pain, sensory/motor deficit, and trophic changes. A majority of the patients 39/65 (60.0%) presented with involvement of 2 or more nerves in the same extremity. Mononeuritis was seen in 26 (40%) patients. The nerves most often involved were the right ulnar nerve in the upper extremity, and the right common peroneal nerve in the lower limb. In general, the nerves of the upper extremity were more commonly involved than in the lower limbs (67 vs. 55). Motor deformities such as claw hand and foot drop were present in 13/75 (20%) and 7/65 (10.8%) patients, respectively. Slit-skin smears were negative in all patients, and skin histopathology from the area of sensory loss revealed non-specific inflammation in the dermis in a majority of patients, with perineural inflammation in a few. All patients were treated with multi-drug therapy (MDT); patients with >/=2 peripheral nerve trunk involvements were treated with WHO MDT MB regimen, while others were administered WHO MDT PB regimen. Follow-up for up to 2 yrs was available in only 32/65 (49.2%) patients, none of whom developed any skin lesions during this period. CONCLUSION PNL is a distinct subset of disease frequently seen in India. There is need to pay more attention to this form of leprosy and diagnose and treat patients earlier to prevent deformities and sequelae of nerve damage.

A Randomized Comparative Study of Oral Corticosteroid Minipulse and Low-Dose Oral Methotrexate in the Treatment of Unstable Vitiligo

Background: Despite continued progress towards elucidation of the biochemical, genetic and immunopathological pathways in vitiligo, a definitive cure remains elusive. The initial therapy must be directed to arrest disease progression. Oral minipulse therapy (OMP) with betamethasone/dexamethasone has been tried and shown to be an effective modality to arrest the disease progression in vitiligo. Objectives: Methotrexate (MTX) is a time-tested effective treatment extensively used in various autoimmune disorders with good efficacy, safety and tolerability on a long-term basis. We intended to compare the efficacy of MTX with that of OMP in patients with unstable vitiligo vulgaris. Patients and Methods: In a prospective randomized open label study, 52 patients with vitiligo were divided into two groups. Patients in group 1 received 10 mg methotrexate weekly. Group 2 patients received corticosteroid OMP which comprised tablets of dexamethasone 2.5 mg (5 tablets), taken on 2 consecutive days in a week (total weekly dose of 5 mg dexamethasone). Results: In the MTX group, among 25 patients analyzed, during the course of treatment for 24 weeks, overall 6 patients developed new vitiliginous lesions. In the OMP group, 7/25 patients developed new lesions. Statistical correlation between the two groups showed no significance in the number of patients who developed new lesions (increasing disease activity) in either of the groups. At the end of the study, it was demonstrated that patients in both groups had a similar reduction in the vitiligo disease activity score. Conclusion: Our study demonstrated that both drugs are equally effective in controlling the disease activity of vitiligo. MTX can be used in patients with active vitiligo, wherever corticosteroids are contraindicated.

Study of desmoglein 1 and 3 antibody levels in relation to disease severity in indian patients with pemphigus

OBJECTIVES To conduct a cross-sectional study to compare Dsg1 and Dsg3 antibody levels independently with severity of disease activity in pemphigus vulgaris (PV) and pemphigus foliaceus (PF). METHODS Blood samples from 44 patients with pemphigus (PV-38, PF-6) were analyzed using ELISA. The severity of skin and mucosal disease was graded using a score from 0 to 3. RESULTS A statistically significant correlation between increase in Dsg 3 antibody titres with severity of oral involvement and Dsg 1 titres with severity of skin involvement was found in both PV and PF patients (p < 0.01). However, we were unable to demonstrate a relationship between increased titres of Dsg1 and Dsg 3 antibodies with oral and skin involvement respectively. CONCLUSION This study suggests that the severity of skin and oral disease in pemphigus is determined by the quantities of Dsg1 and Dsg3 antibodies respectively.

Red scrotum syndrome: idiopathic neurovascular phenomenon or steroid addiction?

BACKGROUND Red scrotum syndrome (RSS) is not infrequent but is often misdiagnosed or underdiagnosed, and seldom reported. The exact etiopathogeneis is still unknown but it almost always follows the prolonged application of topical corticosteroids and is characterised by persistent erythema of the scrotum, associated with severe itching, hyperalgesia and a burning sensation. OBJECTIVE To evaluate the clinicoepidemiological profile and assess the efficacy of various treatment modalities in addition to corticosteroid abstinence in the treatment of RSS. METHODS Twelve patients with RSS, who presented to us during 2010 and 2011, were identified, and various aspects of their illness and treatment were studied. Patch testing was performed in all patients. A skin biopsy was done in seven patients. RESULTS The average age of the patients was 45.83 years (26-62 years). The average duration of illness or the duration of topical steroid use was 27.41 months (6-56 months). Psychiatric comorbidities were seen in 9 (75%) out of 12 patients. Histopathology revealed features resembling erythematotelengiectatic rosacea in four of the biopsied patients. Patch test results were negative. All patients reported improvement of their symptoms within 4 weeks of starting doxycycline with amitriptyline or pregabalin; the treatment had to be continued for 3-4 months. CONCLUSIONS RSS appears to be a manifestation of corticosteroid misuse rather than a primary disease. We suggest that RSS is a rosacea-like dermatosis or steroid-induced rebound vasodilation based on clinical and histopathological features. Our patients responded to cessation of steroids and doxycycline in combination with amitryptaline or pregabalin.

Glycolic acid peels/azelaic acid 20% cream combination and low potency triple combination lead to similar reduction in melasma severity in ethnic skin: Results of a randomized controlled study

Background: Numerous therapeutic options have been tried in the management of melasma. Aims and Objectives: This prospective randomized study was planned to assess the efficacy of low potency triple combination (TC) cream (TC-hydroquinone 2%/tretinoin 0.05%/fluocinolone 0.01%) versus glycolic acid (GA) peels/azelaic acid (AA) 20% cream (GA/AA) combination in melasma. Materials and Methods: Forty patients with melasma were recruited into this study and randomized into two groups. Group A consisting 20 patients received TC cream once a day for night time application for 3 months. Group B comprising of 20 patients received GA/AA 20% cream combination for 3 months. The disease severity was monitored with digital photography, melasma area and severity index (MASI) score, which was calculated at baseline, 6 weeks and 12 weeks, and visual analog scale (VAS) score, which was calculated at baseline and 12 weeks. Results: Of 40 patients, 38 were completed the study. A significant reduction in MASI and VAS was recorded after 6 weeks and 12 weeks of treatment in both groups A and B (P = 0.001). However, there was no significant difference in the mean MASI scores between the two groups at baseline, 6 weeks and 12 weeks. Similarly, there was no difference in the mean VAS scores between the two groups at baseline and 12 weeks. Four patients in group A and 3 in group B experienced adverse effects such as irritation, dryness, and photosensitivity. Conclusion: Both low potency TC cream and GA/AA 20% cream combination are effective in treating melasma among Indian patients.

Dermatoscopic evaluation and histopathological correlation of acquired dermal macular hyperpigmentation

Acquired dermal macular hyperpigmentation (ADMH) is a hypernym encompassing Riehls melanosis, lichen planus pigmentosus, and ashy dermatoses that show significant clinicopathological overlap. We sought to describe the dermatoscopic features of ADMH and correlate them with histopathological findings.

Correlation of vitamin D and vitamin D receptor expression in patients with alopecia areata: a clinical paradigm

Vitamin D (Vit.D) deficiency has been reported in alopecia areata (AA). Downregulation of Vitamin D receptor (VDR) on hair follicles is associated with reduced hair growth.

Disseminated cutaneous Ochroconis gallopava infection in an immunocompetent host: an unusual concurrence – a case report and review of cases reported

Introduction The incidence of deep fungal infections has increased significantly, especially in the background of human immunodeficiency virus (HIV) and immunosuppression. During this period, there has been a parallel emergence in infections due to newer pathogenic fungi that were earlier considered to be non‐pathogenic or saprophytic. Ochroconis gallopava (O. gallopava) is a neurotropic, dematiaceous fungus seldom isolated as a cause of phaeohyphomycosis in humans. Ever since its initial identification as a human pathogen, only 33 reports are available so far, affecting post transplant or immunocompromised patients. It causes severe systemic infections but rarely presents with cutaneous lesions. To the best of our knowledge, there are no reports of O. gallopava presenting primarily as cutaneous lesions in immunocompetent individuals. Herein we report one such case of primary cutaneous phaeohyphomycosis due to O. gallopava in an apparently normal male and briefly review the cases published.

Anaplastic lymphoma kinase-positive primary cutaneous anaplastic large cell lymphoma- Is it a new variant?

Anaplastic large cell cutaneous lymphomas are clinically and pathologically heterogeneous, CD30 + (Ki-1) lymphoproliferative disorders. The importance of anaplastic lymphoma kinase (ALK) positivity is well known in the prognosis of primary systemic anaplastic large cell cutaneous lymphomas; however, the same in primary cutaneous anaplastic large cell cutaneous lymphomas is not much clear. Herein we report a 65-year-old male with an 18-month history of minimally pruritic localized nodulo-plaque lesion over lower back. Histology revealed cutaneous large cell lymphoma and immunohistochemical staining showed positivity for CD30, CD3 and ALK. The role of ALK positivity in pcALCL is discussed in this article.

Clinical, dermoscopic, and trichoscopic analysis of frontal fibrosing alopecia associated with acquired dermal macular hyperpigmentation: A cross sectional observational case-control study

Intervention group 50 95 (91-100) \.0001 58 (51-65) .4551 70 (65-76) .0105 Nonintervention group 56 72 (63-81) 55 (47-62) 61 (54-67) Intervention, aged 11-30 y 26 97 (94-100) \.0001 62 (53-70) .0458 74 (68-79) .0005 Nonintervention, aged 11-30 y 37 69 (58-81) 55 (46-64) 60 (52-67) Intervention, aged 31-50 y 15 96 (90-100) .0009 60 (47-73) .534 72 (64-80) .2416 Nonintervention, aged 31-50 y 13 82 (66-98) 53 (34-71) 62 (47-78) Intervention, aged 51-70 y 9 89 (67-100) \.0001 44 (21-68) .0214 59 (39-79) .7922 Nonintervention, aged 51-70 y 6 67 (33-100) 58 (35-82) 61 (48-75)