Sankha Koley

Efficacy and Safety of Terbinafine Hydrochloride 1% Cream vs. Sertaconazole Nitrate 2% Cream in Tinea Corporis and Tinea Cruris: A Comparative Therapeutic Trial.

Context: To the best of our knowledge, till date no study comparing the efficacy and safety of terbinafine hydrochloride 1% cream and sertaconazole nitrate 2% cream has been done in localized tinea corporis and tinea cruris. Aims: This clinical trial was carried out to study and compare the efficacy of topical terbinafine hydrochloride 1% cream and sertaconazole nitrate 2% cream in localized tinea corporis and tinea cruris and to know the adverse effects of these antifungal creams. Settings and Design: In this prospective, single blind, randomized control trial with two arms, patient were randomized into two groups Group A (treatment with terbinafine cream) and Group B (treatment with sertaconazole cream). A total of 38 patients were enrolled for the study, 20 patients in group A and 18 patients in group B. But five patients of group A and three patients of group B were lost for follow-ups. Therefore sample size was of 30 patients with 15 patients in group A and group B each. Materials and Methods: Patients in group A and B were treated with twice daily topical 1% terbinafine hydrochloride and 2% sertaconazole nitrate cream respectively for a total duration of three weeks. Clinical improvement in signs and symptoms of each clinical parameter, namely itching, erythema, papules, pustules, vesicles, and scaling were graded weekly and clinical cure was assessed. KOH mount and culture was done weekly up to 3 weeks to access mycological cure. Fungal culture was done on Sabourauds dextrose agar with chloramphenicol and cycloheximide. Statistical Analysis Used: Statistical analysis was done using students paired and unpaired t-tests from the data obtained. Results: Comparison between Group A and Group B for complete cure (clinical and mycological) showed that at the end of 3 weeks both terbinafine and sertaconazole groups had 100% complete cure. When the two groups were compared for complete cure, at the end of 1st and 2nd week, statistically non-significant results were observed (P = 0.461 and P = 0.679 respectively). However, at the end of 2nd week, complete cure rate for terbinafine was 80% as compared to 73.35% for sertaconazole with no statistical significance. In both Group A and Group B, clinically significant local side effects like erythema, swelling, stinging sensation, or increased itching were not noticed. A majority of our patients in both the group showed Trichophyton rubrum followed by Trichophyton mentagrophytes growth on culture. In Group A, 11 patients showed growth of T. rubrum, 2 patients showed growth of T. mentagrophytes, and 1 patient had only KOH test positive. In Group B, 10 patients revealed growth of T. rubrum, followed by growth of T. mentagrophytes in 3 and Microsporum canis in 2 patients. The therapeutic response is more or less same in infection with different species. Conclusions: The newer fungistatic drug sertaconazole nitrate 2% cream was as effective as terbinafine hydrochloride 1% cream which is one of the fungicidal drugs, though terbinafine hydrochloride 1% cream has higher rates of complete cure at the end of 2 weeks as compared to sertaconazole nitrate 2% cream. Both the drugs showed good tolerability with no adverse effects.

Congenital cutis laxa with rectal and uterovaginal prolapse

A two-month-old female infant born of a consanguineous marriage, presented with loose, wrinkled and inelastic skin over the neck, axillae, trunk, inguinal region and thighs with slow elastic recoil. Patient also had systemic manifestations in the form of bilateral apical lobe consolidation of lung, bilateral inguinal hernia, rectal and uterovaginal prolapse. Histopathological examination of skin biopsy with special stain for elastic tissue revealed absence of dermal elastic tissue. Genital abnormalities in patients with congenital cutis laxa have been reported rarely. But rectal and uterovaginal prolapse have not been reported at an early age of two months. In the absence of mutational screening, with history and clinical findings our case is likely to be Type I autosomal recessive form of congenital cutis laxa.

Unusual formation of keloids after each episode of recurrent herpes zoster in an HIV positive patient.

Herpes Zoster (HZ) lesions are well known to heal with keloids. As immunity plays an important role in the development of abnormal scars and keloids, the latter is unusual in HIV where immunity is low. We report a rare case of recurrent HZ in an HIV-positive male where the lesions have healed with formation of keloids in both episodes. Within 50 days of last episode, he had an attack of herpes progenitalis.

Melanonychia and skin hyperpigmentation with hydroxyurea therapy

Sir, Hydroxyurea or hydroxycarbamide is an antineoplastic drug used in myeloproliferative disorders (chronic myeloid leukemia, polycythemia vera, and essential thrombocythemia), psoriasis (second-line systemic agent), and AIDS (antiretroviral properties potentiate the activity of the nucleoside reverse transcriptase inhibitor didanosine). The adverse mucocutaneous effects include hyperpigmentation, alopecia, leg ulcers, and lichenoid eruptions. We report a patient who developed hyperpigmentation of the skin and nails 10 weeks after the start of hydroxyurea therapy. A 31-year-old man presented to the dermatology outpatient department with gradually progressive pigmentation of hands, legs, and all finger-nails since 1 month. The pigmentation started from proximal parts of nail plates and progressed distally. The patient was receiving hydroxyurea for chronic myeloid leukemia in a dose of 1 g/day for last three and half months. On examination, diffuse uniform hyperpigmentation was noted on all 10 finger-nails involving approximately half to two-thirds of the nail plates [Figure 1]. Hyperpigmentation was seen on hands and legs with sparing of toe nails. All routine investigations were normal except for mild anemia (hemoglobin 12.2 g/dL and hematocrit 43.8%). All necessary investigations were carried out to eliminate Vitamin B-12 deficiency, hyperbilirubinemia, Addisons disease, Cushings syndrome, hyperthyroidism, hemosiderosis, scleroderma, and HIV. At the time of presentation, he was not taking any other drug that could have caused the nail hyperpigmentation. We considered temporary discontinuation of the drug and restart it to observe the outcome. However, the patient was lost to follow-up. According to causality assessment by Naranjos algorithm, this event could be defined as “probable”.[1] Figure 1 Hyperpigmentation involving hands and all 10 finger-nails; involving proximal half to two-third of the nail plates. Nail grows at a rate of 0.1 mm/day. It takes approximately 100–120 days for the whole nail to grow. Finger nails grow faster than the toe nails. Nail changes as a result of antineoplastic drugs are asymptomatic and entirely reversible within few months after withdrawal of the offending agents. The most frequent presentation of chromonychia (various patterns of nail discoloration) induced by antineoplastic drugs is melanonychia, a dark pigmentation of nails seen in diffuse, transverse, or longitudinal band patterns. It may co-exist with diffuse pigmentation of skin, also known as melanoderma. The mechanism of hydroxyurea-induced melanonychia is still unknown; the potential causes include toxicity affecting the nail bed or nail matrix, focal stimulation of nail-matrix, melanocytes, and photosensitization. The differential diagnosis includes subungual melanoma, pigmented squamous-cell carcinoma, subungual hematoma, nevus, and hyperpigmentation owing to other drugs, including cyclophosphamide, doxorubicin, minocycline, and zidovudine. Aste et al. reported nail hyperpigmentation in nine patients appearing between 6 and 24 months of hydroxyurea-therapy, the commonest presentation being longitudinal melanonychia.[2] Longitudinal melanonychia, diffuse melanonychia affecting all nails and hyperpigmentation of the skin were observed in one patient. However in our case, presentation was noted early; within 10 weeks of starting of therapy. There are reports of progressive transverse melanonychia of all 20 nails within 7 weeks of starting hydroxyurea in a patient of thrombocytosis.[3] Gropper et al. and Issaivanan et al. reported melanonychia of all 20 nails with involvement of all three mucocutaneous areas (skin, nails, and mucosa) in a 63-year-old black woman and a 10-year-old boy, respectively, within 3 months of therapy.[4,5] A dermatomyositis-like eruption was observed in two reported cases.[6] Jeevankumar et al. reported a rare case of hydroxyurea-induced blue lunula.[7] Sometimes both longitudinal melanonychia and periungual hyperpigmentation may be observed together.[8] This presentation may be confused with Hutchinsons sign in malignant melanoma. Ideally, all cases of melanonychia should be distinguished from subungual malignant melanoma. We, therefore, report this interesting case where progressive diffuse melanonychia was observed in all 10 finger-nails with noticeable sparing of the toe nails, associated with pigmentation of hands and legs 10 weeks after starting hydroxyurea therapy.

Elephantine psoriasis with papillomatosis and alternating hypogranulosis and hypergranulosis

Psoriasis is a disease of considerable clinical and histopathological diversity. We report a rare case of elephantine psoriasis responding very well to methotrexate. Histopathology revealed abnormal papillomatosis with finger-like projections in addition to alternating orthokeratosis with overlying hypergranulosis and parakeratosis with overlying hypogranulosis. We believe that this finding may represent an odd histopathologic type in elephantine psoriasis.