Surrinder Kaur

DEXAMETHASONE-CYCLOPHOSPHAMIDE PULSE THERAPY FOR PEMPHIGUS

ABSTRACT: Fifty patients with pemphigus (45 pemphigus vulgaris, 5 pemphigus foliaceus) were treated with dexameth‐asone‐cyclophosphamide pulse therapy. The pulse consisted of 136 mg dexamethasone dissolved in 5% dextrose given in a drip over a period of 1–2 hours on 3 consecutive days. In addition, 500 mg cydophosphamide was added in the drip on the first day. Such pulses were given at monthly intervals. In between the pulses patients were given 50 mg cydophosphamide orally each day. The results were encouraging, the chief advantage being freedom from side effects of corticosteroid therapy. The lesions healed in 3–4 days and the patients were able to resume their work within one week. Further scope of such therapy in pemphigus is discussed.

Lichen planus in childhood: a report of 17 patients.

Abstract: Lichen planus is a dermatosis of unknown origin with a very limited frequency in children. Over a period of one and a half years we observed 17 cases of childhood lichen planus. The classic form of the disease as seen in adults was the most common in these children; unlike adults, however, mucosal and nail involvement was uncommon. The natural history of the disease was similar to that in adults.

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.

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

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.

Dorfman‐Chanarin Syndrome

A 19-year-old man was hospitalized for evaluation of generalized redness and scaling of the skin present from birth. Over the past 8 years he progressively developed knock knees and for the last 6 years he had noticed a patch of hair loss over the scalp. He was born at full term by normal delivery to nonconsanginous parents. Early milestones of development were normal. Subnormal intelligence was detected at 13 years of age when he was found to be weak in school work. There was history of difficulty in getting up from the squatting position. There was no history of diminution of vision, giddiness, or paraesthesias. None of the other family members were similarly affected. Examination revealed an obese man with prominent striae over the abdomen. He looked older than his age. The skin all over the body, including the flexures and the face, was erythematous and covered with whitish grey scales (Fig. 1), The palms and soles showed diffuse hyperkeratosis, and all 20 nails were dystrophic and showed a brownish discoloration. There was a patch of cicatricial alopecia over the scalp (Fig. 2), The head circumference was small (49 cm) and psychodiagnostic tests revealed mild mental retardation (I.Q,, 69), The electroencephalogram was normal. Examination of the muscloskeltal system revealed decreased power (3/5) in quadriceps; other groups of muscles and reflexes were normal. In addition to genu valgum, there was bilateral syndactyly between the 2nd, 3rd, and 4th toes. No hearing defect was detected on audiographic examination. Clinical and electrocardiographic examination of cardiovascular system showed no abnormality. Abdominal examination revealed mild hepatomegaly.

NEVUS DEPIGMENTOSUS IN INDIA: EXPERIENCE WITH 50 PATIENTS

all published in English-language journals. We were surprised to note that otir observation, ptiblished in 1987 in a 100-year-old jouma! referenced in Englishlanguage data bases (2), was omitted. Our patient, a 10-year-old boy at the time of the report, had the disease resolve spontaneously in two weeks without relapse, and he is still in good health six years later. The presence of a purulent rhinitis with soluble meningococcal B antigen in serum and of rotavirus in stools were not noted in other patients. They were discussed as providing an argument for the pathogenesis of Sweet syndrome as a cytokine-related reaction to infection. The benign course should be emphasized, since a significant number of reported patients had severe associated conditions such as osteomyelitis (4 patients), overt leukemia (2), Fanconi anemia (2), or congenital dyserythropoietic anemia (2), and two died.

Fixed drug eruption due to tinidazole with cross-reactivity with metronidazole

A.J. Kanwar, MD, Rajeev Sharma, MD, Murlidhar Rajagopalan, MD, Surrinder Kaur, MD, FAMS, Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh (India) Sir. A large number of drugs are capable of producing fixed drug eruptions [1]. The list has ever been on the increase. A case of fixed drug eruption due to tinidazole is being reported. There was a cross-sensitivity with metronidazole. Case Report. A 32-year-old male patient was examined for a persistent hyperpigmented area over the left buttock of 2 months’ duration. Initially it had appeared as an erythematous patch following ingestion of Fasigyn (tinidazole) prescribed for giardiasis. The erythema and the accompanying burning gradually subsided over a period of 5-6 days leaving behind the pigmented patch. There was no history of exacerbation of the lesion following ingestion of any other drug. Examination revealed a slate-grey, 4 by 3 cm plaque over the left buttock. A ciiagnosis of fixed drug eruption was made and the patient subjected to provocation tests as detailed by Pasricha [2], with the following drugs: acetylsalicylic acid, paracetamol, co-trimoxazole, phe-nobarbitone, sulphadiazine, phenolphthalein, tetracycline and eryth-romycin. None of these drugs produced any activation of the lesion. Then Fasigyn (tinidazole) 500 mg was given as the challenging dose and in about 6 h the patient developed severe itching and marked erythema at the site of lesion on the buttock. Topical corticosteroids were prescribed and after the activity had subsided, the patient was given one tablet of Flagy 1 (metronidazole) 200 mg. Within 4 h of taking this drug ‚ he again developed severe itching and intense erythema on the lesion over the buttock. Comments. Tinidazole is being widely used in the treatment of giardiasis, amebiasis, trichomoniasis and anaerobic bacterial infections. Reported side effects pertain chiefly to the gastrointestinal system. Apart from report of an allergic skin reaction due to tinidazole in 1 patient in a multicenter study [3], there have been no reports of any adverse cutaneous reactions due to this drug. Reappearance of lesion in response to a challenging dose of tinidazole confirms that the fixed eruption was caused by this drug. The patient also showed a cross-reactivity with metronidazole. Tinidazole has close, structural resemblance to metronidazole (fig.l). It differs from metronidazole in having an ethyl group at position 2. There have been only two instances of fixed drug eruptions due to metronidazole [4,5]. The purpose of this report is to alert the physician

Concurrent skin and nerve histology in leprosy and its role in the classification of leprosy.

Concurrent skin and nerve histology was evaluated in 60 leprosy patients (25 BT, 28 BL and 7 LL). The twin aims were to study the comparative histology and the usefulness of nerve histology in the classification of the disease. In BT patients, clinical and histological classification was in agreement in 11 (44%) skin and 17 (68%) nerve biopsies. Concurrent skin and nerve histology was in consonance in 14 (56%) BT patients, while in 6 (24%) patients, only nerve histology was helpful in the classification of the disease, the skin histology being non-specific. Nerve histology was classified as BL in 3 (12%) BT patients, the skin histology was non-specific. In the BL group, the histology of 23 (82.4%) nerve biopsies correlated with the clinical classification, in contrast to skin histology which correlated with clinical assessment in 19 (68%) patients only. In the LL patients, the histology of nerve correlated with the clinical classification in 5 patients (71.4%), compared to histology of the skin in 4 (57%) patients only. The GF was higher in the nerves than in the skin throughout the leprosy spectrum (BT, BL, LL); the difference was, however, marginal in BL leprosy. The average bacteriological index (BI) was higher in nerves (4+) compared to that of skin histology and slit skin smears (3+) in BL leprosy. There was, however, no difference in the BI of the slit skin smears, skin and nerve biopsies in lepromatous leprosy.(ABSTRACT TRUNCATED AT 250 WORDS)

LICHEN PLANUS IN AN 8‐MONTH‐OLD

To tile Editor: In December 1986 we pubiished a paper in Pedlairic Dermatology (Vol. 3. No. 6. pp. 455-458) describing the association of epidermal nevus syndrome with transitional ceil carcinoma of the bladder in a 15-year-old male (!). Recently, at age 20. the same patient developed right shoulder pain in an area underlying the epidermal nevus. A large radiolucent lesion that involved the entire neck of the scapula was identified by x-ray and computed tomographic scanning. The deep mass was removed by curettage followed by bone grafting. The microscopic examination of the specimen reveaied a dense proliferation of chondrobiasts with focal cartilaginous differentiation. In some areas there were scattered muftinucleated giant cells in a myxoid stroma. This histopathology is consistent with chondroblastoma (Fig. 1). Although there have been reports of mesenchymal tumors with epidermal nevus syndrome (2), to our knowledge this is the first report of a neoplasm of cartilaginous origin. This type of tumor is characterized by an essentially benign behavior, although rare metastases and some recurrences have been described (3,4). We believe our case may be another example of the association of epidermal nevus syndrome with an uncommon extracutaneous tumor.