Rahul Mahajan

Contact dermatitis to hair dye: An update

Exposure to hair dyes has long been known as a significant risk factor for development of allergic contact dermatitis among the exposed population as these lead to severe eczema of face and upper trunk in the consumer and hand eczema in hair-dressers. Currently, para-phenylenediamine (PPD) is the main ingredient used in permanent hair color products in the market and is the most important allergen. Prevalence of PPD sensitization is high in patients with contact dermatitis across all continents, with hair dye use being the commonest cause. In order to decrease the burden of disease, use of alternative natural dyeing agents among consumers and use of barrier neoprene gloves among hairdressers should be encouraged apart from stringent legislation to reduce the amount of PPD reaching the consumer.

Randomized controlled study to evaluate the effectiveness of dexamethasone oral minipulse therapy versus oral minocycline in patients with active vitiligo vulgaris.

BACKGROUND Oral minocycline has been recently shown to halt disease progression in active vitiligo. AIMS The present study was planned to compare the efficacy and tolerability of oral minocycline with oral mini pulse (OMP) corticosteroids in active vitiligo. METHODS A total of 50 patients with actively spreading vitiligo were randomized to receive either minocycline 100 mg/day (Group I-25 patients) or OMP 2.5 mg dexamethasone on 2 consecutive days in a week (Group II-25 patients) for 6 months. These were followed-up at every 2 weeks interval. Mean vitiligo disease activity score (VIDA) and mean Vitiligo Area Scoring Index (VASI) were assessed in all patients in addition to the photographic comparison before and after treatment. RESULTS Both groups showed a significant decrease in VIDA from 4.0 to 1.64±0.86 (P<0.001) in Group I and from 4.0 to 1.68±0.69 (P<0.001) in Group II. However, the difference between the mean VIDA scores in the two groups was not statistically significant (P=0.60) at the end of treatment period. The mean VASI declined from 1.71±1.45 to 1.52±1.43 Group I (P=0.06) and from 1.39±1.31 to 1.17±1.34 in Group II (P=0.05). The difference between VASI in Group I and II was not significant at the end of 24 weeks of treatment (P=0.11). CONCLUSION Both dexamethasone OMP and oral minocycline are effective drugs for managing the arrest of disease activity in vitiligo.

Airborne contact dermatitis - current perspectives in etiopathogenesis and management

The increasing recognition of occupational origin of airborne contact dermatitis has brought the focus on the variety of irritants, which can present with this typical morphological picture. At the same time, airborne allergic contact dermatitis secondary to plant antigens, especially to Compositae family, continues to be rampant in many parts of the world, especially in the Indian subcontinent. The recognition of the contactant may be difficult to ascertain and the treatment may be even more difficult. The present review focuses on the epidemiological, clinical and therapeutic issues in airborne contact dermatitis.

Low-dose oral mini-pulse dexamethasone therapy in progressive unstable vitiligo.

Background: The course of vitiligo is unpredictable. If the disease is spreading rapidly, the progression can be controlled with the use of systemic steroids daily or in pulsed form. The present study was planned to assess the efficacy of low-dose dexamethasone oral mini-pulse therapy in progressive unstable vitiligo. Materials and Methods: In this retrospective study, the case records of patients with vitiligo during the period from January 2006 to December 2010 were studied. Patients who had progressive unstable disease were included. These patients were administered oral dexamethasone 2.5 mg per day on 2 consecutive days after breakfast in a week. The patients were asked to come for regular follow-up to assess the arrest of disease activity, relapse of disease activity, and adverse effects. Results: A total of 444 patients were analyzed. In 408 (91.8%) patients, arrest of disease activity was achieved at a mean duration of 13.2 ± 3.1 weeks. In addition, some repigmentation of the lesions was seen in all patients after a mean of 16.1 ± 5.9 weeks. During the follow-up, 50 of 408 (12.25%) patients experienced one or two episodes of relapse in disease activity, which were treated with reinstitution of low-dose dexamethasone oral mini-pulse therapy. The mean disease-free survival (DFS) until the first relapse was 55.7 ± 26.7 weeks, and the mean DFS until the second relapse was 43.8 ± 7.2 weeks. Adverse reactions such as weight gain, lethargy, and acneiform eruptions were observed in 41 (9.2%) patients. Conclusion: Low-dose oral mini-pulse dexamethasone therapy is a good option for arresting progressive unstable vitiligo with minimal adverse effects.

Management of tinea corporis, tinea cruris, and tinea pedis: A comprehensive review.

The prevalence of superficial mycotic infection worldwide is 20–25% of which dermatophytes are the most common agents. Recent developments in understanding the pathophysiology of dermatophytosis have confirmed the central role of cell-mediated immunity in countering these infections. Hence, a lack of delayed hypersensitivity reaction in presence of a positive immediate hypersensitivity (IH) response to trichophytin antigen points toward the chronicity of disease. Diagnosis, though essentially clinical should be confirmed by laboratory-based investigations. Several new techniques such as polymerase chain reaction (PCR) and mass spectroscopy can help to identify the different dermatophyte strains. Management involves the use of topical antifungals in limited disease, and oral therapy is usually reserved for more extensive cases. The last few years have seen a significant rise in the incidence of chronic dermatophyte infections of skin which have proven difficult to treat. However, due to the lack of updated national or international guidelines on the management of tinea corporis, cruris, and pedis, treatment with systemic antifungals is often empirical. The present review aims to revisit this important topic and will detail the recent advances in the pathophysiology and management of tinea corporis, tinea cruris, and tinea pedia while highlighting the lack of clarity of certain management issues.

Pathophysiology of psoriasis

Psoriasis is a chronic inflammatory papulosquamous disease characterized by multiple remissions and relapses. For long, it was believed to be primarily a disorder of keratinization. However, the successful use of traditional immunosupressants and newer immunomodulatory agents in the treatment of psoriasis led to the belief that psoriasis is primarily a disease of Th1 cell immune dysregulation. Recent developments have brought up several new findings such as the role of Th17 cells and evidence of skin barrier dysfunction in psoriasis, akin to atopic dermatitis. The present review aims to focus on these new developments and explain the pathogenesis of psoriasis on the basis of currently available information.

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.

Psoriasis: Epidemiology, clinical features, co-morbidities, and clinical scoring

On the basis of current evidence derived from hospital-based studies, mostly from North India, the prevalence of psoriasis in adults varies from 0.44 to 2.8%, with a much lower prevalence in children. The peak age at onset in adults is in the third and fourth decade of life, with a slight male preponderance. It is recommended that population-based large epidemiologic studies should be undertaken in different parts of the country for estimating the correct prevalence of psoriasis in general population. Chronic plaque-type psoriasis is the most common morphologic presentation of psoriasis, accounting for more than 90% of all cases. Other morphologic variants that deserve special mention include palmoplantar psoriasis, pustular psoriasis, and recalcitrant psoriasis.For epidemiologic purposes, psoriasis can be classified into early and late onset psoriasis. Psoriasis can be classified on the basis of morphology and extent of involvement into localized and widespread disease.For the purpose of clinical trials, psoriasis may be classified as mild psoriasis, moderate psoriasis, and severe psoriasis. The literature shows that there is a significant risk of psoriatic arthritis (7–48%) in patients with plaque-type psoriasis. Hence, it is recommended to evaluate for its presence by detailed history taking and clinical examination, and if necessary, by appropriate radiological investigations. Evidence on the association between plaque-type psoriasis and cardiovascular disease risk factors and ischemic heart disease isinconsistent.On the basis ofavailable evidence, it is prudent to proactively look for metabolic syndrome, dyslipidemia, and obesity, especially in patientswith severe psoriasis (Level 1+ evidence based on systematic reviews and meta-analysis). Based on the current evidence, the psoriasis area severity index appears to be the most valid and reproducible clinical severity score in the management of adult patients with plaque-type psoriasis.

Reactive Arthritis in India: A Dermatologists' Perspective

Background: The mucocutaneous lesions in Reiter syndrome (RS) or reactive arthritis are seen quite frequently. Materials and Methods: The case records of patients admitted with the diagnosis of RS from January 2006 to December 2010 were reviewed. Data regarding the demographic details; course of musculoskeletal, mucocutaneous, and ophthalmic involvement; body surface area affected; morphology of lesions; investigations undertaken; and treatment instituted were recorded. Based on these, the disease was classified as complete or incomplete RS. Results: The case records of 11 patients were evaluated. There were seven males and four females. Only two patients had complete RS, whereas nine patients had incomplete RS. Arthritis and mucocutaneous involvement were seen in all 11 patients, whereas preceding urethritis/dysentery was seen in 4 patients and eye symptoms in 4 patients. Enthesitis was seen in eight patients (72.7%). Circinate balanitis/vulvitis was present in six patients and keratoderma blenorrhagicum in eight patients. The most frequent radiologic finding was juxta-articular osteopenia in eight patients. Conclusion: RS may not show the typical triad in all cases, although musculoskeletal disease is seen in a significant proportion of patients. In the absence of typical signs and symptoms, cutaneous manifestations may help establish the diagnosis of RS.

Wolf's isotopic response: Report of a case and review of literature

“Wolfs isotopic response” refers to the occurrence of a new dermatosis at the site of previously healed dermatosis. A number of factors including viral, neural, vascular, and immunologic factors have been implicated in the causation of this peculiar response but none has been proven conclusively. Here, we report a case where lichen planus developed at the site of dermatofibrosarcoma protruberans that had been previously treated with surgery and radiotherapy. We also put forth a hypothesis on the genesis of isotopic response considering the above mentioned factors.