Ravindra V. Koranne

The Spectrum of Skin Disease Among Indian Children

Abstract:  Skin diseases in children are encountered frequently and their characterization is essential for the preparation of academic, research and health plans. A retrospective study was designed to evaluate the epidemiologic features of pediatric dermatoses in India. The setting was a tertiary care referral center in India (Kalawati Saran Children’s Hospital, New Delhi) during January 1997 to December 2003. A total of 30,078 children less than 12 years of age with 32,341 new dermatoses were recorded, with a male to female ratio of 1.07:1. Most of the disease was seen in the 1‐ to 5‐year age group (44.94%). The most common skin diseases were infections and infestations (47.15%) consisting of bacterial infections (58.09%) and scabies (21.54%), followed by eczemas (26.95%), infantile seborrheic dermatitis, scabies, and pityriasis alba. Other unique dermatoses in our settings were papular uticaria (3.59%), miliaria (5.46%), postinflammatory pigmentary abnormalities (1.68%), and nutritional deficiency dermatoses (0.45%). A majority of patients were diagnosed clinically and special diagnostic tests were conducted in 2.6% of patients. The most common diagnostic test used was KOH mount (59.2%), followed by skin biopsy (39%). Nearly 90% of patients were seen without any referral and in the remaining, a majority were referred by pediatricians (75%). A majority of patients were diagnosed to have infection followed by dermatitis in our setting.

Clinico-Bacteriological Study of Pyodermas in Children

One hundred cases of pyodermas in children were investigated clinically and bacteriologically. Nasal and throat swabs from all cases were subjected to bacteriological examination. Most of the children (42%) were in the 1–4 year age group. The majority (58%) belonged to lower socio‐economic groups with poor standards of hygiene. A history of overcrowding was obtained from 87% of cases, 82% were undernourished. Most of the children (68%) reported during the hot and humid months of June, July, August, and September. Primary pyodermas were observed in 72% of the children, and secondary pyodermas in 28%. Impetigo was the commonest primary pyoderma (48.61%); among secondary pyodermas, infected scabies was noted predominantly (42.86%). The face and legs were more commonly involved.

Spontaneously Improving Michelin Tire Baby Syndrome

Abstract: Michelin tire syndrome is described in a 22‐month‐old girl of Indian origin who had generalized folding of the skin, esotropia, epicanthic folds, and delayed speech. Histopathology showed diffuse lipomatous hypertrophy. The skin changes showed partial improvement on follow‐up. We report this case because of its rarity. Furthermore, the spontaneous improvement is significant, unlike the persistent course of other congenital nevi.

Diagnosing multibacillary leprosy : A comparative evaluation of diagnostic accuracy of slit-skin smear, bacterial index of granuloma and WHO operational classification

BACKGROUND In view of the relatively poor performance of skin smears WHO adopted a purely clinical operational classification, however the poor specificity of operational classification leads to overdiagnosis and unwarranted overtreatment while the poor sensitivity leads to underdiagnosis of multibacillary (MB) cases with inadequate treatment. Bacilli are more frequently and abundantly demonstrated in tissue sections. AIMS AND METHODS We compared WHO classification, slit-skin smears (SSS) and demonstration of bacilli in biopsies (bacterial index of granuloma or BIG) with regards to their efficacy in correctly identifying multibacillary cases. The tests were done on 141 patients and were evaluated for their ability to diagnose true MB leprosy using detailed statistical analysis. RESULTS A total of 76 patients were truly MB with either positive smears, BIG positivity or with a typical histology of BB, BL or LL. Amongst these 76 true-MB patients, WHO operational classification correctly identified multibacillary status in 56 (73.68%), and SSS in 43 (56.58%), while BIG correctly identified 65 (85.53%) true-MB cases. CONCLUSION BIG was most sensitive and effective of the three methods especially in paucilesional patients. We suggest adding estimation of bacterial index of granuloma in the diagnostic workup of paucilesional patients.

Perforating folliculitis with jaundice in an Indian male: a rare case with sclerosing cholangitis.

our experience with six patients does suggest several conclusions. Firstly, there does not appear to be an increased frequency of adverse reactions to high-dose tetracycline in patients with localized EBS. Secondly, two-thirds of our patients did indeed experience reduced disease activity while on prolonged tetracycline therapy, based on objective, standardized, lesional counts. Thirdly, the response lasted during at least 4 months of treatment, rather than representing a transient effect seen only at 2 but not at 4 months of treatment. Fourthly, no decreases in lesional counts occurred following treatment with placebo. Although the limited number of patients completing therapy precludes statistical validation of this intervention, based on our encouraging experience in four of our six wellstudied patients, coupled with the lack of any other known effective treatment for this disease, we would recommend empirical treatment with tetracycline of any EBS patient who is willing to risk the known adverse side-effects of this drug and who is sufficiently symptomatic to desire an attempt at systemic therapy. It could even be used in children at risk for tetracycline-induced dental discoloration if the severity and chronicity of their symptoms justified such treatment, given how easily permanent crowns could be placed in these patients if cosmetic dental intervention were necessary and desired at a later age.

An interesting case of colocalization of segmental lichen planus and vitiligo in a 14‐year‐old boy

A 14‐year‐old boy had segmental vitiligo (L3−4) on the right thigh and leg for 4 years, and was advised to apply topical clobetasol propionate, 0.05%, in the night, with daily sun exposure for 10 min, as he refused to comply with topical psoralens. As there was no response to therapy even after 3 months, the patient stopped the steroid cream but continued with the sun exposure. Subsequently, the patient noticed gradual‐onset, itchy, violaceous, pigmented, raised lesions superimposed on the vitiligo macules. Cutaneous examination revealed violaceous, polygonal papules, 0.5 × 0.5 cm in size, some of which coalesced to form discrete violaceous plaques, confined to areas of vitiligo, with a clear‐cut demarcation from normal skin ( Fig. 1 ). The scalp, palms, soles, nails, and mucosa were normal. Histopathology of the polygonal papules revealed hyperkeratosis, wedge‐shaped hypergranulosis, irregular acanthosis with saw toothing of the rete ridges, basal cell liquefaction, and a band‐like lymphocytic infiltrate ( Fig. 2 ), consistent with lichen planus. The patient was subsequently prescribed fluticasone propionate (0.05%) ointment once daily for the lesions of lichen planus. There was a marked improvement in the lesions of lichen planus after 1 month.

A study of leprosy reactions in a tertiary hospital in Delhi.

A retrospective study of 531 leprosy patients was undertaken to study the profile of reactions in the post Multi‐Drug‐Therapy period in a tertiary hospital in Delhi. BT was the most common group. The prevalence of reactions was found to be 8.09% for the Type 1 and 4.70% for the Type 2 reactions for a male:female ratio of 2.2. The Type 1 reaction was most frequently observed in the BB group followed by BL, BT and LL groups respectively. More than half of the patients had reactions at the time of presentation. In only 39.8% of the patients did reaction follow Multi‐Drug‐Therapy. In 4.5% of the patients with Type 1 reactions (T1R), concomitant infections were noted. The most common presentation of T1R was cutaneous lesions (74.41%) followed by cutaneous lesions and neuritis (53.6%), neuritis alone (12.1%), and only edema of hands and feet (7.31%) respectively. The Type 2 reactions (T2R) presented chiefly as papulo‐nodular (92%) lesions followed by pustulonecrotic (8%) lesions. Associated neuritis was found in 40% and periosteitis and iritis in 8% and 4%, respectively. In 8.6% of the patients with T2R, precipitating factors could be observed. The prevalence of deformities in patients with reaction was 25%, and was more common in females. Deformities were observed in 23.25% of the T1R patients and 28% of the T2R patients.

Ocular scrofuloderma with unilateral proptosis.

Proptosis due to an extraconal orbital abscess of tubercular origin with lacrimal gland involvement, representing ocular scrofuloderma, is a rare entity. This association has not been reported earlier in the literature. We describe a 7‐year‐old boy who presented with nodulo‐ulcerative lesions of tubercular etiology with discharging sinuses on right side of the face and a similar lesion on the right lower eyelid along with proptosis of 4 months duration. Computerized tomography (CT) scan of the head confirmed the extraconal, intraorbital, hyperdense, homogeneously enhancing mass separated from the lateral rectus muscle and further revealed involvement of lacrimal gland along with erosion of the temporal bone. The patient showed marked improvement of his dermatological and ophthalmological lesions with anti‐tubercular treatment. Subsequent ultrasound examinations of the orbit revealed regression in the size of the abscess from 10.7 mm to 5.0 mm and then complete disappearance of the abcess obviating surgical intervention.

Tuberculosis of the vulva masquerading as a sexually transmitted disease

Tuberculosis of the vulva is a rare condition usually seen by a gynecologist. We report a case of chronic ulcer on the vulva of four months duration, which, on detailed investigation, turned out to be a case of primary inoculation tuberculosis. The patient was subsequently put on antitubercular therapy with a good the therapeutic response. The rarity of this presentation in dermato‐venereology is emphasized.

Erythroderma in Children : A Clinico-Etiological Study

Although there are various published studies on erythroderma from western and Asian countries, most of them have only included patients in the adult age groups. As we have an exclusively pediatric dermatology unit, we thought it would be intriguing to study the clinical, etiological and laboratory parameters of erythroderma in children.