Shilpa Garg

Combination therapy in the management of atrophic acne scars

Background: Atrophic acne scars are difficult to treat. The demand for less invasive but highly effective treatment for scars is growing. Objective: To assess the efficacy of combination therapy using subcision, microneedling and 15% trichloroacetic acid (TCA) peel in the management of atrophic scars. Materials and Methods: Fifty patients with atrophic acne scars were graded using Goodman and Baron Qualitative grading. After subcision, dermaroller and 15% TCA peel were performed alternatively at 2-weeks interval for a total of 6 sessions of each. Grading of acne scar photographs was done pretreatment and 1 month after last procedure. Patients own evaluation of improvement was assessed. Results: Out of 16 patients with Grade 4 scars, 10 (62.5%) patients improved to Grade 2 and 6 (37.5%) patients improved to Grade 3 scars. Out of 22 patients with Grade 3 scars, 5 (22.7%) patients were left with no scars, 2 (9.1%) patients improved to Grade 1and 15 (68.2%) patients improved to Grade 2. All 11 (100%) patients with Grade 2 scars were left with no scars. There was high level of patient satisfaction. Conclusion: This combination has shown good results in treating not only Grade 2 but also severe Grade 4 and 3 scars.

Surgical scar revision: An overview

Scar formation is an inevitable consequence of wound healing from either a traumatic or a surgical intervention. The aesthetic appearance of a scar is the most important criteria to judge the surgical outcome. An understanding of the anatomy and wound healing along with experience, meticulous planning and technique can reduce complications and improve the surgical outcome. Scar revision does not erase a scar but helps to make it less noticeable and more acceptable. Both surgical and non-surgical techniques, used either alone or in combination can be used for revising a scar. In planning a scar revision surgeon should decide on when to act and the type of technique to use for scar revision to get an aesthetically pleasing outcome. This review article provides overview of methods applied for facial scar revision. This predominantly covers surgical methods.

Generalized granuloma annulare treated with monthly rifampicin, ofloxacin, and minocycline combination therapy.

Granuloma annulare (GA) is a disease characterized by granulomatous inflammation of the dermis. A variant form of the disease, generalized granuloma annulare (GGA), can be observed in 15% of affected patients. Localized GA is likely to resolve spontaneously within months or a few years, whereas GGA can persist for decades. There are various therapies for treating GGA. Monthly combination therapy of rifampicin 600 mg, ofloxacin 400 mg, and minocycline 100 mg (ROM) is used for treating paucibacillary leprosy which shares both clinical and histopathologic similarities with GA. Therefore, we decided to evaluate the possible efficacy of monthly ROM in a patient with GGA.

Intralesional immunotherapy for difficult to treat warts with Mycobacterium w vaccine

Background: Immunotherapy is an evolving therapeutic modality for the treatment of warts. We conducted a study to assess the efficacy and safety of intralesional Mycobacterium w vaccine for the treatment of warts at sites that were difficult to treat. Materials and Methods: Thirty patients with at least one wart present on either the plantar surface of their feet, palms, volar aspect of their fingers, or periungual or subungual region, were treated with 0.1 ml of killed Mycobacterium w vaccine given intralesionally in a single wart, without any prior sensitisation dose. Thereafter, a single injection of 0.1 ml of vaccine was given at intervals of four weeks in a single wart till there was complete resolution of the warts or a maximum of 10 injections. Treatment was stopped if there was no response after three injections. The patients were followed up for at least six months. Results: Out of the 30 patients, 28 (93.33%) patients had complete resolution of their warts, both at the injected and distant sites. The mean (SD) time for complete clearance of warts was 43.71(32.82) days and the mean (SD) dose of vaccine that was required for complete clearance of warts was 0.186 ml (0.101). Four patients (14.28%) had a recurrence of warts. The treatment was well-tolerated and the side effects were reversible in the majority of the patients. Conclusion: In comparison to the earlier studies using Mycobacterium w vaccine for the treatment of warts, our study was different in the following aspects: No sensitisation dose was given, only a single wart was injected at a time and the duration between the period of injections was increased to four weeks. With all these changes we eliminated the complications due to the sensitisation dose and achieved good results. This study provides new insight into the dose and schedule of treatment of this evolving therapeutic modality.

Syphilitic hepatitis: An uncommon manifestation of a common disease

Hepatitis being first manifestation of secondary syphilis is rare. Here in we report a case of 39 years old male who was being treated for hepatitis and presented to us subsequently with itchy maculopapular rash. Venereal disease research laboratory (VDRL) titre was 1:16. Treponema pallidum hemagglutination assay (TPHA) was positive. He was treated with intramuscular Benzathine Penicillin. His hepatitis improved rapidly.

Monthly rifampicin, ofloxacin, and minocycline therapy for generalized and localized granuloma annulare.

BACKGROUND The localized form of granuloma annulare is usually self-limiting, resolving within 2 years. Generalized granuloma annulare, on the other hand, runs a protracted course, with spontaneous resolution being rare. It is also characterized by a later age of onset, an increased incidence of diabetes mellitus, poor response to therapy, and an increased prevalence of HLA Bw35. OBJECTIVE To assess the efficacy of monthly pulsed rifampicin, ofloxacin, and minocycline (ROM) therapy in the management of granuloma annulare. METHODS Six biopsy proven patients of granuloma annulare were included in the study, five of the generalized variety, and one localized. Three of these patients were resistant to standard modalities of treatment. All six patients were treated with pulses of once monthly ROM till complete resolution of all lesions. Results were analyzed in terms of complete resolution of lesions and side effects. Presence of comorbid conditions was noted. RESULT All six patients were successfully treated with 4-8 pulses of monthly ROM. None of the patients reported any adverse effects. LIMITATIONS Small sample size and the lack of a control group are limitations. CONCLUSION Treatment with pulses of once monthly ROM caused complete resolution of lesions in both localized and generalized granuloma annulare, even in cases recalcitrant to conventional therapy. There were no side effects in any of the patients. Larger trials are needed to substantiate the efficacy of monthly ROM in granuloma annulare.

Development and validation of a Hindi language health-related quality of life questionnaire for melasma in Indian patients.

Background: Melasma, which is fairly common in Indians, causes significant emotional and psychological impact. A Hindi instrument would be useful to assess the impact of melasma on the quality of life in Indian patients. Objective: To create a semantic equivalent of the original MELASQOL questionnaire in Hindi and validate it. Methods: A Hindi adaptation of the original MELASQOL (Hi-MELASQOL) was prepared using previously established guidelines. After pre-testing, the Hi-MELASQOL questionnaire was administered to 100 women with melasma visiting the out-patient registration counter of Safdarjung Hospital, Delhi. These women were also administered a Hindi equivalent of the Health Related Quality of Life (HRQOL) questionnaire. Melasma area severity index (MASI) of all the participants was calculated. Results: The mean MASI score was 20.0 ± 7.5 and Hi-MELASQOL score was 37.19 ± 18.15; both were highly, positively and significantly correlated. Reliability analysis showed satisfactory results. Physical health, emotional well-being and social life were the most adversely affected life domains. Limitations: It was a single-center study and the number of patients studied could have been larger. Conclusion: Hi-MELASQOL is a reliable and validated tool to measure the quality of life in Indians with melasma.

Impact of vitiligo in afflicted patients

Diseases affecting the skin are visible to others; therefore, patients with skin diseases not only cope with the effect of the disease, but also with the reaction of people to their disease. Skin color plays an important role in an individual′s perception of health, desirability, worth and wealth. Vitiligo presents as milky-white patches in the skin and/or mucosae which can result in psychosocial distress and social stigmatization. Vitiligo has a profound impact on the quality of life (QoL) of the patient. Vitiligo affects emotional, physical, social, psychological and occupational aspects of the QoL of an individual. An empathetic and supportive doctor-patient interaction, information regarding vitiligo, prompt treatment, good social support, psychotherapeutic interventions or psychotropic therapy can help the patient to live with their disease, and to manage the associated psychosocial and psychiatric comorbidity.

Anetoderma-like presentation of cutaneous mastocytosis

General and systemic examination was normal. Dermatological examination revealed multiple round to oval normoto hyper-pigmented macules [Figure 1] and soft pouch‐like papules (anetoderma like) [Figure 2] mainly over trunk and few over extremities over flexor as well as extensor aspect, sparing the face, ranging in the size between 0.3 and 1 cm in diameter. On stroking the lesions developed wheel and erythema (Darier’s sign positive) [Figure 3].

Congenital erythropoietic porphyria: An unusual presentation

Congenital erythropoietic porphyria is a rare autosomal recessive disorder of heme biosynthesis that results from the deficient activity of uroporphyrinogen III synthase. Herein, we report a case of an 8-year-old boy who presented with red-colored urine, erythrodontia, hypertrichosis, and skin fragility with minimal scarring over dorsa of the hands and tip of the nose, but without the classical history of photosensitivity, blistering, or mutilation of photo-exposed parts.