Sandipan Dhar

Methotrexate in childhood psoriasis.

Abstract: We treated childhood psoriasis with methotrexate (MTX) in seven children (4 boys, 3 girls) over 7.5 years. Their ages and duration of disease varied from 3.5 to 16 years (mean 12.14 yrs) and 4.8 months to 5 years (mean 2.2 yrs), respectively. Psoriatic erythroderma was seen in three patients, generalized pustular psoriasis in two, recalcitrant psoriasis and psoriatic arthropathy in one each. Pre‐MTX liver biopsy performed in 4 children showed grade I changes. Methotrexate was given in a single weekly oral dose of 3.75 to 25 mg (mean 16.6 mg). The duration of treatment necessary to control the disease varied from 6 to 10 weeks (mean 7.9 wks). Total duration of MTX therapy was 31.2 to 46.4 weeks (mean 38.8 wks). Posttherapy disease‐free interval ranged between 14.4 and 16.8 weeks (mean 15.5 wks). Follow‐up after withdrawal of MTX was 16 to 28 weeks (mean 22.3 wks). Total cumulative MTX dose ranged from 390 to 960 mg (mean 683.6 mg). Side effects were nausea and vomiting in three patients.

Evaluation of minor clinical features of atopic dermatitis.

Abstract: The diagnostic significance of 19 previously proposed minor features of atopic dermatitis was evaluated. The frequency of these features was studied in 50 patients with typical atopic dermatitis compared to that in 50 control subjects. The ages of all individuals ranged from 3 months to 12 years. Six of the minor features, chelitis, nipple eczema, perifollicular accentuation, white dermographism, recurrent conjunctivitis, and anterior neck folds, were encountered as often in patients as in controls. Two additional features that were of diagnostic significance were diffuse scaling of the scalp and infraauricular fissuring.

Drug Related Involvement of Specific Sites in Fixed Eruptions: A Statistical Evaluation

Different drugs produce fixed eruptions over different parts of the body. However, the significance of preferential site involvement in fixed eruptions due to specific drugs has not been statistically evaluated. One hundred and twenty five patients of fixed drug eruption (FDE) were studied to examine this question.

TREATMENT OF MELASMA WITH POTENT TOPICAL CORTICOSTEROIDS

A.J. Kanwar, MD, Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012 (India) Melasma in a pattern of acquired hyper-melanosis seen mostly in women of child-bearing age and occasionally in males occurring on sun-exposed areas. It is often considered either as a physiological change in pregnancy, or oral contraceptives are incriminated. The condition may fade after delivery but is often persistent [1]. Distribution-wise, the lesions are centrofacial (63%), malar (21%) and mandibular (16%) [2]. On Wood’s lamp examination, melasma is classified as epidermal, dermal and compound (epidermal and dermal). Histopathologically, the pigmentation is either epidermal or dermal. This differentiation has clinical significance as epidermal pigmentation responds better to therapy whereas dermal pigmentation is usually resistant to all forms of treatment. Kligman and Willis [3] reported good response with a combination of 0.1% tretinoin, 5% hydro-quinone and 0.1% dexamethasone, but depigmentation was not attainable when any of the components was omitted; however, a double-blind study with 2% hydroquinone and 1% retinoic acid without any corticoste-roid produced an equally good response [2]. We recently treated 10 patients with melasma (7 females and 3 males) with a potent topical corticosteroid, i.e. clobetasol propionate (0.05%). The ages of the patients ranged from 20 to 40 years, and the duration of melasma was from 3 to 14 months. Of 10, 5 had centrofacial, 4 malar and 1 mandibular patterns of distribution. None of the female patients were pregnant or on oral contraceptives at the time of examination or in the preceding 6 months. Patients were instructed to apply clobetasol propionate (0.05%) cream topically initially twice daily for 4 weeks followed by once daily for another 4 weeks. In all patients fading of pigmentation was observed after 2 weeks, and it was more discernible after 4-6 weeks. Eighty to ninety percent clearance of pigmentation was observed after 6-8 weeks in 7 patients; in 3 therapy had to be stopped after 4 weeks because of local atrophy and telangiectasiae. In addition to the topical corticosteroid, patients were advised to use a sun screen. In 4 of 7 patients in whom the pigmentation had cleared, it reappeared at the same sites after about 2-3 weeks after stopping the treatment and gradually progressed to pretreatment state during the next 4–6 months of follow-up. Though Wood’s light and histopatholog-ical examination were not done to categorize the therapeutic response, initial clearance of pigmentation with clobetasol propionate was encouraging though the success was shortlived. Kligman and Willis [3], however, failed to find any beneficial effect of only topical

Epidemic of hand, foot and mouth disease in West Bengal, India in August, 2007: A multicentric study

Background: Hand, foot, and mouth disease (HFMD) is caused mostly by Coxsackievirus A16 (CA16) and enterovirus 71 (EV71). Epidemic of HFMD has occurred in India only once in Kerala in 2003. We report here a recent outbreak of HFMD in three districts of West Bengal, India. Materials and Methods: A case detection system developed with 1) three private clinics in three districts; two at Howrah and one at Hooghly, 2) Pediatrics Department of two medical colleges in Kolkata, 3) 12 practioners of these three districts with 4) a central referral center at Department of Dermatology, NRS Medical College, Kolkata where all cases from this system were confirmed by a single observer. Pediatric Dermatology unit of the Institute of Child Health, Kolkata was another independent unit. Results: A total of 38 cases of HFMD were reported till 08.10.07. Age group ranged from 12 months to 12 years (mean 40.76 months, SD 29.49). Males were slightly higher than females (M:F - 21:17). Disease was distributed mostly over buttocks, knees, hands, feet - both dorsum and palmar or the plantar surface and the oral mucosa. Highest severity noted over the buttocks and the knee. Healing time for skin lesions was 6-13 days (mean 9.13 days, SD 1.93). Oral lesions were found in 33 (86.8%) cases. Conclusion: This outbreak far away from the initial one confirmed regular outsourcing of the virus with possibilities of future epidemics. Also the fact that EV71 induced epidemic is on rise in this part of globe is alarming for India. We hope this early report will be of help for strategic planning for a better management of the disease and prevention of dreaded neurological complications in India.

Factors responsible for death in patients with pemphigus.

The records of 10 patients who died with pemphigus have been examined for factors affecting and contributing to death. Early initiation of therapy, the age at onset of the disease, and the mode of administration of corticosteroids, conventional or in pulse form, did not affect the survival. The cutaneous involvement was extensive in all 10 patients; it ranged between 30‐80%. Septicemia was the commonest event preceeding death; in 4 cases, it was due to Staphylococcus aureus.

Further Experience With Pemphigus in Children

Abstract: Seven children had pemphigus: six had pemphigus vulgaris and one pemphigus foliaceus. Four who had pemphigus vulgaris were administered dexamethasone pulses. Follow‐up from six months to one year was uneventful; the disease was under control and there were no complications due to therapy. Our observations suggest that the clinical features, course, and principles of therapy for pemphigus in children are essentially the same as those in adults.

Photosensitive Lichenoid Eruption due to Enalapril

Amrinder J. Kanwar, Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh (India) Cutaneous reactions to enalapril, an angiotensin-converting enzyme inhibitor, are relatively less frequent as compared to capto-pril [1]. We describe a patient who developed a photosensitive lichenoid eruption shortly after starting enalapril for essential hypertension. A 44-year-old housewife presented with erythematous lichenoid papular scaly plaques on the forehead and extensors of the forearms of 3 weeks’ duration. The lesions were moderately itchy. She was diagnosed to have essential hypertension about 6 months back for which she was prescribed nifedipine 10 mg three times a day. However, as the blood pressure was not under control, enalapril 10 mg twice a day was substituted about 6 weeks back by her general practitioner. There was no history of any other drug intake. The lichenoid eruption was considered to be due to enalapril, and on its withdrawal and treatment with topical corticoste-roids and systemic antihistaminics, the rash resolved over a period of 3 weeks. Angiotensin-converting enzyme inhibitors are being increasingly prescribed in patients with hypertension as these are highly effective and relatively free from side effects. Though cutaneous adverse effects with enalapril have been reported [2, 3], these are much less as compared to captopril because enalapril does not contain the thiol group which is thought to be responsible for skin eruption. The resolution of the lesions on withdrawal of enalapril suggested it to be due to this drug. The patient did not agree to a challenge test. References Moots RJ. Keeling PJ. Morgan SH: Aduli Schönlein-Henoch purpura after enalapril Lancet 1992;340:304-305. Furness PN, Goodfield MJ. MacLennan KA et al: Severe cutaneous reactions to captopri and enalapril: Histopathological studies an¢ comparison with mycosis fungoides. J Clii Pathol 1986;39:902-907. Barnes JN, Davies ES, Gent CB: Rash, eosin ophilia and hyperkalemia associated with ena lapril. Lancet 1983;i:41-42.

Colocalization of vitiligo and psoriasis in a 9-year-old boy.

To the Editors: Information on reticulate pigmentary disorders is scant (1) and these disorders have not been adequately highlighted in standard dermatology texts. DowlingDegos disease (DDD), reticulate acropigmentation of Kitamura (RAPK), and acropigmentation of Dohi are some of the entities in this heterogeneous group (2). Cases reported in non-Japanese populations are of special interest (3,4). A substantial number of cases of DDD and RAPK have been reported from India (5-9). The first author has reported a series of cases from northern India (9). However, acropigmentation of Dohi is a rarely reported entity in India (10). To the best of our knowledge, so far only one case has been reported (9). We herein describe an additional case recently seen by us. A 12-year-old boy had 1 to 4 mm angulated, dark brown, frecklelike lesions symmetrically distributed over the dorsa of both hands and feet for the last 5 years. In addition, multiple 1 to 3 mm depigmented macules were interspersed in the same distribution. There was no atrophy over the macules or palmar pits or breaks in the epidermal ridge pattern. No other site was affected. None of his family members had a similar skin problem. He was diagnosed as acropigmentation of Dohi. Skin biopsy was refused by the patient. Acropigmentation of Dohi has mostly been reported in Japanese individuals (11). A combination of angulated, nonatrophic, dark brown, frecklelike macules over the dorsa of the hands without palmar pits establishes the diagnosis. Of 12 cases studied by Dohi (1920) and reported by Komaya (1 l), 10 were boys and 2 were girls. Our present patient also was a boy. However, the earlier case seen by the first author was a girl (9). Although this entity is known to be transmitted as an autosomal dominant trait (1 I), neither the boy’s parents nor his two sisters had a similar type of pigmentation. This can be explained on the basis of spontaneous mutation or incomplete penetrance. The girl reported earlier also had no affected family members (9).

ORAL MINIPULSE THERAPY IN VITILIGO

Dr. A.J. Kanwar, Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, 60012 Chandigarh (India) Though various modalities of treatments are available for vitiligo, none is uniformly effective. Systemic corticosteroids have been used in the treatment of vitiligo presuming it to be autoimmune in nature [ 1 ]. In order to reduce the side-effects, it can be administered in ‘pulse’ form with beneficial effects [2]. ‘Oral minipulse’ (OMP) therapy implies use of cyclical pulse dose corticosteroids in much smaller doses compared to the usual pulse therapy. Therefore, the sideeffects are further minimized, and this therapy can be used by patients at home with regular follow-up at the clinic [3]. Recently Pasricha and Khaitan [4] tried corticosteroid OMP therapy in 40 vitiligo patients with encouraging results. We report herein our results with OMP in vitiligo. Thirty-seven patients (23 male, 14 female) with rapidly spreading vitiligo covering more than 2% body surface area were recruited. Their ages ranged from 6 to 46 years (mean 22.62 years), and the duration of disease varied from 1.5 months to 5 years (mean 1.81 years). Of 37 patients, 31 (83.8%) had vitiligo vulgaris, while 6 (16.2%) had segmental vitiligo. All patients were screened for any contraindication for systemic corticosteroids. A single dose of OMP in adults consisted of 10 tablets of dexamethasone (0.5 mg each) given on 2 consecutive days in a week after breakfast in the morning. In children ( < 16 years old) the dose was halved. A minimum of 5 doses and a maximum of 25 doses were tried. No other treatment was prescribed during the study period. The therapeutic response was graded as no response, weak, moderate, excellent response and total clearance. Patients were reviewed every 5 weeks by the senior author. Thirty-two (86.4%) patients completed the trial, while 5 (13.6%) defaulted. In 14 (43.8%) patients, new lesions stopped appearing and there was mild to moderate repigmentation, while in 18 (56.2%) there was no response (table 1). Patients who showed a response mostly showed repigmentation within the first 15 weeks (doses) of treatment. Patients with segmental vitiligo were worst