Ramesh M Bhat

Topical formic acid puncture technique for the treatment of common warts

Abstract

Pyoderma gangrenosum: An update

Pyoderma gangrenosum (PG) is an uncommon, distinctive cutaneous ulceration which is usually idiopathic, but may be associated with many systemic disorders. The etipathogenesis of of PG is still not well understood. Clinically it is classified into ulcerative, pustular, bullous and vegetative types. A few atypical and rare variants have also been described. The diagnosis mainly depends on the recognition of evolving clinical features as investigations only assist in the diagnosis. In view of this a few criteria have been proposed for the diagnosis of PG. the treatment mainly consists of corticosteroids and immunosuppressive agents. A few new agents have also been tried in the management.

A Comparative Study of the Efficacy of 4% Hydroquinone vs 0.75% Kojic Acid Cream in the Treatment of Facial Melasma.

Background: Melasma is a common acquired cause of facial hyperpigmentation seen predominantly among females with significant psychological and social impact. It is often recalcitrant to treatment. Several topical hypopigmenting agents have been used to combat melasma. Hydroquinone and Kojic Acid are well established monotherapeutic agents for treating melasma. Objectives: This study focuses mainly on the efficacy of once daily application of 4% Hydroquinone and 0.75% Kojic Acid cream (containing 0.75% Kojic acid and 2.5% vitamin C) so as to determine an effective modality of treatment for facial melasma. Materials and Methods: A total number of 60 patients with facial melasma attending the Out-patient department of Dermatology, Venerology and Leprosy, Fr. Muller Medical College Hospital, Mangalore from Oct 2008-April 2010 were studied. Patients were allocated alternately to group A and group B. Group A patients received 4% Hydroquinone cream and group B patient received a Kojic Acid cream (which contained 0.75% Kojic acid and 2.5% vitamin C) and were advised to apply topically once daily at night. Patients were followed up on 4th, 8th and 12th week. At each visit side effects were noted and clinical response to treatment was calculated using the MASI score. Statistical Methods: Chi square test, student ‘t’ test. Results: At the 4th week post treatment evaluation, facial hyperpigmentation responded early to 4% Hydroquinone cream than to 0.75% Kojic Acid cream. At the end of 12 week treatment period, 4% Hydroquinone cream had an overall superiority to 0.75% Kojic Acid cream as a topical hypopigmenting agent. Conclusion: The results of the study show that 4% Hydroquinone cream is a better topical hypopigmenting agent with rapid rate of clinical improvement when compared to 0.75% Kojic Acid cream.

Pyoderma Gangrenosum in childhood.

Pyoderma Gangrenosum is a rare, ulcerative, necrotizing cutaneous disorder of unknown etiology. 1 The lesions usually present as a painful nodule or pustule that breaks down to form a progressively enlarging ulcer with a raised tender, undermined edge. 1 Pyoderma Gangrenosum was first described by Brunsting et al. in 1930, 2 but the pathogenesis is still not clear. Local infection does not appear to be an etiologic factor even though Brunsting initially suggested this may be the cause. 1–3 Its association with various autoimmune diseases and its response to immunosuppressive therapy suggests an immunologic basis for the disease. 4,5 The characteristic feature of pyoderma gangrenosum is the development of lesions at sites of trauma: also known as pathergy phenomenon. Most cases of pyoderma gangrenosum occur mainly between the third and fifth decades of life, though disease can occur anytime between the first and ninth decades of life. 6 We present a case of pyoderma gangrenosum in a 3‐year‐old boy, and review the features of pyoderma gangrenosum in children.

Pyoderma gangrenosum: an Indian perspective

Background.  Pyoderma gangrenosum (PG) is an uncommon, idiopathic, neutrophilic skin disease sometimes associated with systemic diseases. To our knowledge, there have been no case series of PG reported from India.

Safety and efficacy of low-dose isotretinoin in the treatment of moderate to severe acne vulgaris

Background: Isotretinoin is indicated for moderate to severe cases of acne which are unresponsive to conventional therapy. The classical recommended dose is 0.5 to 1.0 mg/kg/day. As the side effects are dose related, low-dose isotretinoin therapy for acne is an attractive option; however, but little data exists on the safety and efficacy of this strategy. Materials and Methods: In this prospective, non-comparative study, 50 participants, both male and female, having moderate to severe acne vulgaris were enrolled and treated with isotretinoin at a dose of 20 mg/day (approximately 0.3-0.4 mg/kg/day), for a period of 3 months. Participants were evaluated by means of clinical and laboratory investigations before starting isotretinoin. Investigations were repeated at the end of the first and third months following completion of treatment, and participants were followed up for 6 months to look for any relapse. Results: At the end of the treatment, very good results were observed in 90% of participants. Cheilitis was the most common among the side effects observed and was seen in 98% of the participants. One participant developed vitiligo as a side effect, which is a new finding, and has not reported in literature before. Elevated serum lipid levels were observed in 6% of the participants, and relapse occurred in 4% of the participants over a 6 month follow up period. Conclusion: Three months of treatment with low-dose isotretinoin (20 mg/day) was found to be effective in the treatment of moderate to severe acne vulgaris, with a low incidence of serious side effects. This dose also was more economical than the higher doses.

Cutaneous lymphangiectasia of the vulva secondary to tuberculosis

Cutaneous lymphangiectasia, also called as acquired lymphangioma, is a benign cutaneous disorder involving the dermal and subcutaneous lymphatic channels. It can rarely occur on the vulva. We describe a 35-year-old woman who came with multiple raised lesions over the vulva and left upper thigh of 1 year duration. She gave history of getting treated for multiple swellings that developed over right side of the neck and inguinal regions on both sides three decades ago. On local genital examination, the patient had a large polypoidal growth involving both sides of the vulva, left upper thigh, and over pubic area. Multiple linear scars were present over the upper thighs and groin bilaterally. The patient underwent simple vulvectomy and left thigh growth excision. Histopathological examination of the vulvectomy specimen confirmed our diagnosis.

A comparative study of 10% KOH solution and 5% imiquimod cream for the treatment of Molluscum contagiosum in the pediatric age group

Background: Although Molluscum contagiosum (MC) is a self-limiting condition, active therapy could prevent further spread and improve cosmesis. Most of the available treatment modalities traumatize the lesions and have to be undertaken in the hospital, therefore evoking panic in children. In the quest for an alternative therapy, this study comparing 10% potassium hydroxide (KOH) solution and 5% imiquimod cream was taken up. Aims and Objectives: To compare the efficacy and tolerability of 10% KOH and 5% imiquimod in the treatment of MC. Materials and Methods: This comparative study was conducted over a period of 18 months from October 2011 to March 2013, 40 patients between the age group of 1-18 years with clinically diagnosed MC were divided into two groups (lottery method), 20 patients were treated with 5% imiquimod cream (Group A) and the other 20 were treated with 10% KOH solution (Group B). Patients were followed up on the 4 th , 8 th and 12 th week of treatment. Results: At the end of 12 weeks, out of 20 patients who received 10% KOH, 17 patients showed complete disappearance, whereas out of 20 patients who received 5% imiquimod, only 10 patients showed total clearance of the lesions. Adverse events were more frequent with 10% KOH, pigmentary disturbances being the most common. Conclusion: With only minor adverse effects, 10% KOH is an inexpensive and efficient modality for the treatment of MC in the pediatric age group. Although 5% imiquimod was effective in clearing the lesions with minimal adverse effects, the longer duration required for its efficacy may deter its wider use.

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.

Long-term efficacy and safety of itolizumab in patients with moderate-to-severe chronic plaque psoriasis: A double-blind, randomized-withdrawal, placebo-controlled study

trial, and a trial by Ortonne et al. Table I summarizes their efficacy results. The PRESTA and PRISTINE trials found that the 50mg BIW/QWregimen resulted in statistically greater percentages of patients with disease improvement by week 12 and continuing through week 24. Ortonne et al did not statically compare the 2 dosing regimens, but nominally, the percentage of patients who achieved PASI 75 at week 24 is greater for the BIW/QW regimen. For adalimumab, Asahina et al evaluated dosing regimens of 40 mg EOW and 80 mg loading dose followed with 40 mg EOW. Two limitations for this study were (1) the loading dose plus maintenance regimen did not match the FDA-approved regimen and (2) the 2 dosing regimens were not statistically compared against each another. Both dosing regimens led to statistically greater percentages of patients achieving PASI 75 than patients in the placebo group. Table I illustrates that the loading dose plus maintenance regimen led to nominally greater proportions of patients with PASI 75 at every time point over the 40 mg EOW regimen. However, without appropriate statistical analysis, we cannot infer any difference in effect between these two dosing regimens. Currently, there is not sufficient evidence to conclude that there is a difference in effectiveness between the 2 dosing regimens. With regard to safety, all of the studies examined for both etanercept and adalimumab showed that the rates for adverse events were not statistically different between the differing dosing regimens. In conclusion, the etanercept data have shown that, startingwith a loading dose results in amore rapid and higherpercentageofpsoriatic skin improvement up to 24 weeks. For adalimumab, there are no data directly comparing the efficacy of loading dose plus maintenance andmaintenance-only dosing regimens, and future studies should address this gap.