Sunil Dogra

Epidemiology of Childhood Vitiligo: A Study of 625 Patients from North India

Abstract: To study the clinical and epidemiologic profile of childhood vitiligo, we retrospectively analyzed the data of children with vitiligo attending the pigmentary clinic of our center. Of the 625 children seen over 10 years, 357 (57.1%) were girls and 268 (42.9%) were boys. As compared to adult patients with vitiligo, this sex difference was found to be statistically significant (p < 0.001). The mean age of onset of the disease was 6.2 years. Vitiligo vulgaris (generalized vitiligo) was the most common type, followed by focal, segmental, acrofacial, mucosal, and universal, in that order. The most frequent site of onset was the head and neck, followed by the lower limbs, trunk, upper limbs, and mucosae. Leukotrichia was present in 77 patients (12.3%), while Koebner phenomenon was observed in 71 patients (11.3%). Halo nevi were observed in 29 patients (4.4%). Seventy‐six patients (12.2%) had a family history of vitiligo. Eight patients (1.3%) had an associated autoimmune disease. These associated disorders were alopecia areata in two patients, and diabetes mellitus, thyroid disease, Addison disease, polyglandular syndrome, and pemphigus vulgaris in one patient each.

Quality of life in patients with vitiligo

Vitiligo is an important skin disease having major impact on quality of life of patients, many of whom feel distressed and stigmatized by their condition. Society greets vitiligo patients in much the same way as it does any one else who appears to be different. They are started at or subjected to whispered comments, antagonism, insult or isolation. The chronic nature of disease, long term treatment, lack of uniform effective therapy and unpredictable course of disease is usually very demoralizing for patients suffering from vitiligo. It is important to recognize and deal with psychological components of this disease to improve their quality of life and to obtain a better treatment response.

Epidemiological characteristics of leprosy reactions: 15 years experience from north India.

A retrospective analysis of patients leprosy clinic records at PGIMER, Chandigarh, India for the period 1983 to 1998 was undertaken to study the frequency, time of onset, and risk factors for leprosy reactions. Of the 2600 cases analyzed, 1494 were multibacillary and 1106 had paucibacillary disease. Presentation with reaction was common with 30.9% of our patients having reactions at the time of first visit. The incidence of reversal reaction (RR) was highest during 6 to 12 months after starting multi-drug therapy (MDT), thereafter declining gradually. Late RR occurred in 9.5% of all cases and was noted up to 7 years after treatment. Female gender, widespread disease, and multibacillary disease were identified as risk factors for RR. Erythema nodosum leprosum (ENL) reactions were noted to occur mostly during second or third year after starting MDT. Of the total number of patients who experienced ENL, 64.3% had recurrent episodes which continued for up to 8 years after the start of treatment. Lepromatous leprosy, female gender, and high Bacterial Index (>/=3) were recognized as risk factors for developing ENL. Occurrence of recurrent and late reactions, even though of mild severity, highlights the importance of recognizing and treating them promptly to prevent or reduce morbidity, complications, and further deterioration in the disability status. Although it is hoped that leprosy will have been eliminated at all levels by 2005, the recognition and management of these reactions will continue to be the most essential/significant task in the post elimination era.

Dermatology Life Quality Index score in vitiligo and its impact on the treatment outcome

SIR, A 40-year-old man reported the slow progressive appearance, during the previous 6 years, of pruritic erythematous lesions on the trunk, buttock, abdomen, axilla, genital area and forearm (Fig. 1a). Lesions consisted of follicular papules, comedones, milia and cysts. Lesional areas were alopecic (Fig. 1b), and diffuse alopecia was also present on the scalp and beard area, along with comedones and cysts. The patient reported severe skin dryness, especially in the involved areas. No impairment of salivary or lacrimary function was noted. Serological and haematological tests were all normal or negative. Because of the diffuse presence of cysts and comedones, a diagnosis of chloracne had been made in another institution; the clinical diagnosis was confirmed histologically by the presence of infundibular cysts and a granulomatous foreign body reaction to keratin scales. A further biopsy was performed: the most striking histological feature was a lymphocytic infiltrate involving eccrine glands and coils along with a characteristic epithelial hyperplasia (Figs 1c,d). This picture fits perfectly with that reported in the literature as being characteristic of syringolymphoid hyperplasia, also known as syringotropic mycosis fungoides or syringotropic cutaneous T-cell lymphoma (CTCL). The hair follicles were involved by the lymphocytic infiltrate in a manner similar to that of the eccrine glands. Follicles were surrounded by a dense lymphocytic infiltrate, with extensive exocytosis. Occasional Pautrier microabscesses were evident in the follicular sheath. This pattern is that of pilotropic mycosis fungoides, a form of folliculotropic CTCL. Many follicles were entirely trans-

Clinical study of repigmentation patterns with different treatment modalities and their correlation with speed and stability of repigmentation in 352 vitiliginous patches

Because the etiopathogenesis of depigmentation in vitiligo is still obscure, the source of pigmentation in the repigmentating lesion and its stability is also not fully known. Several authors have shown on histopathology and electron microscopy predominantly a perifollicular spread of pigment. The aim of this study was to clinically assess the types of repigmentation patterns obtained with different treatment modalities and their correlation with speed and stability of repigmentation. A total of 125 patients with vitiligo on treatment with psoralens (topical and systemic psoralen-UVA [PUVA]), steroids (both topical and systemic), and topical calcipotriol, alone or in combination were enrolled. Representative lesions of vitiligo excluding mucosal sites were selected in each patient and photographed at baseline. Repigmentation was assessed and labeled as marginal, perifollicular, diffuse, or combined. The preselected patches were evaluated at 3 months to assess the speed of repigmentation. Retention of pigment (stability) was noted at 6 months, after the stoppage of active treatment. Of the 352 vitiligo patches selected, 194 (55%) showed predominant perifollicular repigmentation, of which a majority (127; 65.5%) were on systemic PUVA and 35 (18%) were on topical PUVA. Diffuse pigmentation was observed in 98 patches (27.8%) of which 66 (67.3%) were on topical steroids. Marginal repigmentation was seen in 15, of which the majority (80%) were on systemic PUVA and topical calcipotriol. Of the 28 total lesions showing marked repigmentation at 3 months, 22 lesions pigmented in a diffuse manner, 2 in a perifollicular pattern, and 4 showed a combined type of repigmentation. On follow-up, marginal repigmentation was the most stable (93.3%), followed by perifollicular (91.7%) and combined type (84.4%). Diffuse repigmentation was the least stable (78.5%). Psoralens predominantly exhibit a perifollicular pattern of repigmentation and steroids (topical/systemic), a diffuse type. The speed of repigmentation is much faster when initial repigmentation is of the diffuse type as compared with follicular repigmentation. The marginal and perifollicular repigmentation is more stable than the diffuse type of repigmentation.

Epidemiology of onychomycosis in patients with diabetes mellitus in India.

Background The number of individuals diagnosed with diabetes mellitus is increasing worldwide. Although onychomycosis is often observed in diabetics, there have been no large studies of its epidemiology in this patient group in India.

Narrow-band UVB for the treatment of vitiligo: an emerging effective and well-tolerated therapy

Background  Vitiligo is an acquired depigmentation disorder of great cosmetic importance, affecting 1% of the general population. Photochemotherapy is the most commonly used treatment modality in extensive vitiligo, but is associated with many short‐ and long‐term side‐effects. Recently, narrow‐band ultraviolet B (NBUVB) therapy has been reported to be an effective and safe therapeutic option in patients with vitiligo. We studied the efficacy and safety of NBUVB (311 nm) therapy in Indian patients with generalized vitiligo.

Comparative efficacy of cetirizine and fexofenadine in the treatment of chronic idiopathic urticaria

objectives: Antihistamines are the first line of therapy for chronic idiopathic urticaria (CIU). The present study was designed considering the lack of reports comparing the efficacy and safety of commonly prescribed cetirizine and fexofenadine in the treatment of CIU. methods: A total of 116 patients, aged 17 to 65 years, with CIU (urticarial wheals for at least two days per week for six consecutive weeks before entry) were enrolled in this randomised double‐blind study. Study period was 28 days with patient visits on days 14 and 28 for investigator evaluation of the clinical response. Patient evaluation was on the basis of an analogue scale. Final response to treatment was judged as symptom free, partial improvement, and no improvement. results: Ninety‐seven patients (52 cetirizine, 45 fexofenadine) completed the study. The response to treatment in both the groups at the end of treatment period was as follows; symptom free {cetirizine 27(51.9%), fexofenadine 2(4.4%)}, partial improvement {cetirizine 19(36.5%), fexofenadine 19(42.2%)}, no improvement {cetirizine 6(11.5%), fexofenadine 24(53.3%)}. Side effects noted were mild with no significant difference between the two. conclusion: Cetirizine seems to have therapeutic advantage over fexofenadine in the treatment of CIU.

Topical tacrolimus for treatment of childhood vitiligo in Asians.

Childhood vitiligo is a common disorder of pigmentation in India. Considering the lack of uniformly effective and safe treatment modalities for children with vitiligo, search for newer therapeutic agents continues. This study was designed to evaluate the role of topical tacrolimus in the treatment of childhood vitiligo. Twenty‐five children with vitiligo were treated with topical 0.03% tacrolimus ointment applied twice daily for 12 weeks. Response was noted as marked to complete (> 75% repigmentation), moderate (50–75% repigmentation) and mild (< 50% repigmentation). Twenty‐two children (9 boys and 13 girls) of mean age 7.2 ± 1.4 years completed the study. Twelve (54.5%) children had vitiligo vulgaris, nine (40.9%) had focal vitiligo and one (4.5%) had segmental vitiligo. The mean duration of disease was 8 ± 3 months. Nineteen (86.4%) children showed some repigmentation at the end of 3 months and other three had no response. Of these 19 children, repigmentation was marked to complete in 11 (57.9%), moderate in five (26.3%) and mild in three (15.7%) children. Side effects were minimal, such as the pruritus and burning noted in only three patients. Topical tacrolimus is an effective and well‐tolerated treatment modality in Asian children with vitiligo.

Systemic Methotrexate Treatment in Childhood Psoriasis: Further Experience in 24 Children from India

Abstract:  Well‐designed studies on systemic therapeutic modalities for severe psoriasis in children are rare. Children with severe disease are treated with the support of data extrapolated from that in adult, although management in them differs from adults in several important aspects. Like other systemic modalities, data regarding the use of methotrexate in the treatment of childhood psoriasis is meager. This study aims to analyze the efficacy and safety of methotrexate in severe or disabling childhood psoriasis. The records of all the patients <18 years of age treated with systemic methotrexate at the psoriasis clinic of our institute from January 1993 to December 2006 were retrieved. Information regarding demographic profile, disease characteristics, response to treatment, side effects, etc. was noted from predesigned clinic proforma. Indications of methotrexate use were baseline psoriasis area and severity index (PASI) >10, disease refractory to conventional therapies and disabling psoriasis even though the psoriasis area and severity index was <10. Clinical status of patients was assessed at weekly intervals for the first 2 weeks, fortnightly during next month and then monthly. Response to therapy was graded as good (50–75% decrease in PASI) and excellent (>75% decrease in PASI). Laboratory investigations to detect methotrexate induced toxicity were performed at regular intervals. Of the 29 patients treated with methotrexate, 24 were eligible for the final data analysis. Indication for the institution of methotrexate therapy was severe disease, viz., extensive recalcitrant plaque type psoriasis in 17 patients, erythroderma and generalized pustular psoriasis of von‐Zumbusch type in three patients each and severe disabling palmo‐plantar involvement along with chronic plaque lesions in one patient. Response to therapy was excellent (>75% decrease in PASI) in all but two patients. The mean time to control the disease, i.e., 50% reduction in PASI was 5.1 weeks. Mean total cumulative dose of methotrexate in the first episode was 215 mg. The duration of remission could be calculated in nine patients only, varying from 1.5 months to 3 years. Side effects were mild, observed in nine children, which included nausea, vomiting, and loss of appetite. Methotrexate is an effective, cheap, easily available, and reasonably safe drug to be used in severe childhood psoriasis under an expert supervision and laboratory monitoring.