Shyam Sunder Pandey

Pattern of skin and nail changes in chronic renal failure in Nepal: A hospital-based study

Chronic renal failure, regardless of its cause, often produces specific dermatological abnormalities, which can develop long before failure manifests clinically. Our aim was to study the clinical pattern of skin and nail changes in chronic renal failure and also study the associations of these changes with age, sex, etiology and duration of the chronic renal failure. A total of 104 diagnosed cases of chronic renal failure were included in the study over a period of 1 year. Equal numbers of age‐ and sex‐matched individuals were taken as controls. The male : female ratio was 1.4:1. The mean duration of chronic renal failure was 19 ± 20 months. Among cases and controls, 72% and 16% had skin changes, respectively. Xerosis was the most common of the skin changes (28%), followed by hyperpigmentation (20%), pruritus (15%), infectious diseases (5%) and other skin changes (33%) in chronic renal failure patients. Abnormal nail changes were seen in 82% of the cases compared to only 8% of the controls. In the cases, white nail was most common followed by brown and half‐and‐half nail. Pruritus was significantly higher in the dialysis group whereas the nail changes were significantly higher in the non‐dialysis group. The skin and nail changes were common in chronic renal failure and manifested in various forms. Thus, thorough inspection of the integument might reveal markers of occult renal disease.

Tachyphylaxis to histamine-induced wheal suppression by topical 0.05% clobetasol propionate in normal versus croton oil-induced dermatitic skin

BACKGROUND Patients often tell about reduced effectiveness of topical steroids on repeated use. Tachyphylaxis to these agents has been demonstrated in humans for vasoconstriction and histamine-induced wheal suppression in normal skin, but not in diseased skin. Relevance of these data to diseased skin is not clear. Further, the clinical impression does not appear to match tachyphylaxis shown in normal skin with regard to the time course. OBJECTIVES To examine whether tachyphylaxis to histamine-induced wheal suppression by a topical steroid occurs in dermatitic skin and to determine its time course vis-à-vis normal skin. METHODS Pharmacodynamic response to 0.05% clobetasol propionate applied daily under occlusion was measured by histamine-induced wheal suppression assay in 10 individuals. This test was performed on a steroid-treated normal site, on a steroid-treated site where dermatitis was induced by occlusive application of 40% croton oil, and on a vehicle-treated site in each individual at different intervals up to 14 days. RESULTS Suppression of wheal volume started from second day in steroid-treated sites. There was significant difference in the wheal volume in steroid treated normal vs. dermatitic sites from day 2 to day 10. Maximum wheal suppression occurred earlier in dermatitic skin (day 4 vs. day 6). After this, the volume of wheal started increasing and became equal to control (complete tolerance) on 12th day in dermatitic skin and on 14th day in normal skin. CONCLUSIONS Time courses of tachyphylaxis to the action of 0.05% clobetasol propionate were significantly different in normal skin and dermatitic skin. Complete tolerance occurred earlier in dermatitic skin compared to normal skin.

Leprosy care through traditional healers.

A n encouraging increase i n the knowledge of leprosy has been found in traditional healers after training has been given . Evaluation was by preand post-training questionnaires to which scores were assigned. Their role in leprosy care at the community level i s also being discussed . The traditional healer is part and parcel of the social milieu where he commands respect and has an intimate relationship with his clientele. Considering the present manpower in the National Leprosy Control Programme we can think of this alternative approach as a boost. In addition, the negative aspects of health care as practised by many practitioners can also be corrected by the appropriate training.

Clinico-mycological study of dermatophytic infections and their sensitivity to antifungal drugs in a tertiary care center

Background: Worldwide, dermatophytic infections are running a chronic course either due to ineffective treatment or emerging drug resistance. In the past three decades, there has been an increase in incidence and non-responsiveness to conventional antifungals, which suggests that there is a need of antifungal sensitivity testing. Aims: This study was aimed at identifying clinico-mycological pattern of dermatophytic infections in patients attending thedermatology outpatient department of a tertiary care hospital, and to obtain the sensitivity pattern of isolates against six commonly used oral antifungals (fluconazole, terbinafine, itraconazole, ketoconazole, griseofulvin and voriconazole). Methods: Patients with suspected dermatophytoses attending the outpatient department of Sir Sunderlal Hospital, Varanasi, were enrolled in the study. A detailed history, clinical examination and sample collection for mycological examinations was done. In vitro antifungal sensitivity testing was done on species isolated from culture as per the Clinical and Laboratory Standard Institute M38-A standards, with broth microdilution method. Results: There were 256 patients recruited in the study, with a male: female ratio of 3:1. The most commonly affected age group was 20–40 years (52.4%). Tinea corporis et cruris was the most common type observed (27.2%). Potassium hydroxide positivity was seen in 211 samples (79.6%) and culture positivity was found in 139 samples (52.4%). The most common species identified was Trichophyton mentagrophytes (75.9%). Sensitivity testing was done on fifty isolates of T. mentagrophytes. Minimum inhibitory concentrations of itraconazole, ketoconazole, terbinafine and voriconazole were comparable, while griseofulvin showed the highest minimum inhibitory concentration. Itraconazole was found to be the most effective drug, followed by ketoconazole, terbinafine and fluconazole. Griseofulvin was the least effective drug among the tested antifungals. Limitations: This is a hospital-based study, and may not reflect the true pattern in the community. Sensitivity pattern of only one species T. mentagrophytes was carried out. Conclusion: Inadequate and irregular use of antifungal drugs has led to the emergence of resistant strains, which cause poor treatment outcomes. Thus, it is very important to test for antifungal sensitivity to check for resistance to antifungals.

Hypohidrotic ectodermal dysplasia

Ectodermal dysplasias (ED) are a group of inherited disorders characterized by dysplasia of structures of ectodermal origin, clinically classified into hypohidrotic and hidrotic forms. A 21-year-old female presented with history of hypohidrosis, thinning of scalp and eyebrow hair, xerotic skin, and periorbital and perioral wrinkling. There was hypodontia and peg-shaped teeth on intraoral examination. Routine investigations were normal, orthopantomogram revealed absence of multiple teeth with peg-shaped teeth. Histopathological examination showed thinned epidermis and reduction in the number of eccrine units. Thus, the diagnosis was confirmed as Hypohidrotic ED.

Effectiveness of Conventional Drug Therapy of Plaque Psoriasis in the Context of Consensus Guidelines: A Prospective Observational Study in 150 Patients

Background Evidence for superior outcome by adhering to therapy guidelines is imperative to their acceptance and adaptation for the optimal management of disease variants. Objective Comparative study of prospective outcomes in simultaneous consideration of independent variables in groups of 150 patients of plaque psoriasis either treated adhering to or in digression of standard guidelines. Methods The psoriasis area severity index (PASI) and the dermatology life quality index (DLQI), prior to and after three months of uninterrupted therapy were examined in treatment groups among 150 patients. Recovery rates of 75% or more in PASI were compared. Independent variables were also examined for their bearing on the outcome. Results The vast majority was early onset disease phenotype. All three treatment regimens when administered in adherence to the guidelines yielded significantly superior rates of defined recovery both in PASI and DLQI. Compromise of the therapeutic outcome appeared in high stress profiles, obesity, female sex and alcohol, tobacco or smoking habit. Conclusion Conventional drug therapy of plaque psoriasis yields superior outcome by adhering to the consensus guidelines. Psychiatric address to stress must be integral and special considerations for phenotypic/syndromic variants is emphasized for effective therapy of psoriasis.

Brooke-spiegler syndrome: a rare entity.

Brooke-Spiegler syndrome (BSS) is a rare autosomal dominant disorder characterized by the presence of various adnexal tumors including multiple cylindromas, trichoepitheliomas and spiradenomas. A 35-year-old female presented with multiple asymptomatic nodular lesions over face and scalp since the age of 5 years. There were no complaints suggestive of systemic involvement. Her son, elder sister, younger sister, father, fathers sister, and grandmother had history of similar lesions. On examination, there were multiple asymptomatic skin-colored firm papulonodular lesions measuring from 2 to 8 mm in diameter, with smooth surface mainly affecting central part of face. Scalp showed pinkish, firm, smooth-surfaced, dome-shaped nodules measuring about 1 to 3 cm in size. Histopathological examination was consistent with trichoepitheliomas for the facial lesions and cylindromas for the scalp lesions. The diagnosis of BSS was thus confirmed.

Role of caffeine in the management of androgenetic alopecia

Androgenetic alopecia (AGA) is hereditary and androgen-dependent, progressive thinning of the scalp hair that follows a defined pattern. It is a common dermatological problem affecting both men and women, with significant negative impact on their social and psychological well being.[1] It commonly begins by 20 years of age and affects nearly 50% of men by the age of 50 years.[1] Its etiopathogenesis is mainly androgen dependent and modulated via the testosterone metabolite dihydrotestosterone (DHT) and the expression of hair follicle-related androgen receptor.[2] The genetic factors also have been implicated in the pathogenesis of AGA.[2] Patients afflicted with AGA suffer from severe impairment of quality of life and thus treatment of this condition is mandatory, requiring long-term treatment with chief concerns about the efficacy and safety of the product used. Currently only oral finasteride and topical minoxidil are approved for treatment of AGA. [3,4] Recently, certain newer advances have shown caffeine to have beneficial effects in patients suffering from AGA. The proposed mechanism which would counteract DHT-induced miniaturization of the hair follicle include inhibition of phosphodiesterase by caffeine, which increases cAMP levels in cells and therefore promotes proliferation by stimulating cell metabolism.[5] A study conducted by Fischer et al. used hair organ culture model to investigate the effects of testosterone and caffeine on hair follicle growth stimulation. This in vitro study used scalp biopsy samples from male AGA patients which were cultivated using different concentrations of testosterone and/or caffeine for a period of 120-192 hours. Addition of caffeine in concentrations of 0.001% and 0.005% were found to counteract the suppressive effects of testosterone on hair growth, with a higher hair shaft elongation seen at 120 h after caffeine administration, compared to control group. This in vitro study thus clearly demonstrates that caffeine is a stimulator of human hair growth which may have importance in the treatment of AGA.[5] Brandner et al. proved by their double-blind placebo-controlled trial that caffeine application causes a substantial reduction in the transepidermal water loss in men compared to women, thus improving barrier function in men.[6] Regarding the route of delivery of caffeine, hair follicles are considered an important route for drug delivery. A recent study which assessed the follicular penetration of topical caffeine in hair follicles proved hair follicles to be faster route of drug delivery for topically applied drugs.[7] An important requirement for the treatment of AGA is follicular drug delivery. A recent study assessed the follicular penetration of caffeine on topical application in a shampoo formulation for 2 min and showed that penetration via hair follicles was faster and higher compared with the interfollicular route and that hair follicles were the only pathway for faster caffeine absorption during the first 20 min after application.[8]

Familial type IIa hyperlipoproteinemia presenting with different types of xanthomas

A 12-year-old non-obese male presented with multiple yellowish, non-tender soft papulonodular lesions over multiple sites along with firm, subcutaneous swellings along achilles tendons bilaterally since the age of 2 years. There was no history of similar complaints in family. Lipid profile revealed high levels of serum cholesterol and low density lipoproteins. Histopathological examination revealed diffuse dermal infiltrate of foamy histiocytes. He was diagnosed as a case of Type IIa hyperlipoproteinemia with different types of xanthomas. The patient was adviced dietary fat intake control and started on tablet atorvastatin 40 mg daily. Complete work up of all the other family members was adviced.

Annular alopecia areata: report of two cases.

Alopecia areata (AA) is an auto-immune disorder characterized by the appearance of non-scarring bald patches affecting the hair bearing areas of the body. Scalp is the most common site of involvement. AA can affect any age group. The usual pattern of the hair loss is oval or round. We hereby, report two cases of annular and circinate pattern of AA due to its unusual morphology.