Sushil Pande

An open, nonrandomized, comparative study of imiquimod 5% cream versus 10% potassium hydroxide solution in the treatment of molluscum contagiosum.

BACKGROUND There are numerous therapeutic modalities available for treatment of molluscum contagiosum. However, the ablative modalities are painful and not suitable for children. AIM We aimed to evaluate and compare the safety and efficacy of 2 of the painless modalities, viz., 5% imiquimod cream and 10% potassium hydroxide (KOH) solution, in the treatment of molluscum contagiosum. METHODS Out of a total of 40 patients of molluscum contagiosum in the study, 18 patients in the imiquimod group and 19 patients in the KOH group completed the study. The given medication was applied by the patient or a parent to mollusca at night, 3 days per week. Imiquimod was continued till clinical cure; and 10% KOH, till lesions showed signs of inflammation. Assessments of response and side effects were performed at the end of week 4, week 8, and week 12. Significance was tested by Students t test and Mann-Whitney test. RESULTS The mean lesion count decreased from 22.39 to 10.75 with imiquimod and from 20.79 to 4.31 with KOH at the end of 12 weeks. We found complete clearance of lesions in 8 (44%) patients with imiquimod and in 8 (42.1%) patients with 10% KOH. Minor side effects were seen in 15 (78.9%) patients on KOH and 10 (55.5%) patients on imiquimod. CONCLUSIONS The results of this study suggest that both 5% imiquimod cream and 10% KOH solution are equally effective in molluscum contagiosum though KOH has a faster onset of action. However, KOH solution is associated with a higher incidence of side effects.

Methods of specimen collection for diagnosis of superficial and subcutaneous fungal infections.

The diagnosis of mycotic infections is contingent upon the The most important steps for the successful isolation of proper selection, collection and transport of the appropriate etiological agents of mycoses are proper collection, rapid clinical specimen. An active, ongoing interaction among the transport, prompt and correct processing of the specimens clinician, microbiologist and pathologist often facilitates and their inoculation onto appropriate culture media at the correct diagnosis and an accurate interpretation of the suitable temperatures. culture and histopathological results. It is very important that the laboratory receives the correct type of specimen with Superficial mycosis adequate clinical data to enable it to carry out the proper Skin lesions should be sampled from the erythematous, investigations. peripheral, actively growing margins of the lesions. Skin should be decontaminated with 70% alcohol to remove SITE OF COLLECTION OF A SPECIMEN FOR CUTANEOUS surface bacterial contamination. An open, sterile petri dish is held immediately below the area to be sampled and skin scales can be flaked into it by using the blunt edge of a It is important to remember that cutaneous lesions may sterile surgical blade or microscopic slide. When there is little not only represent primary diseases but may also be an scaling as with lesions of the glabrous skin, it is preferable extension of a serious disseminated fungal infection. to use cellophane tape or vinyl tape strips to take adequate Histoplasma capsulatum, for example, can be primarily material.[1,2] The cellophane strip is pressed against the recovered from the respiratory tract but may also be lesion, peeled off and placed adhesive side down on a clean MYCOSIS

Phenomena in dermatology.

For a better understanding of various dermatoses, it is imperative for any physician practising dermatology to have a good theoretical knowledge of the underlying pathophysiologic processes involved in various systemic diseases involving the skin. For an easy grasp over this topic, we have discussed the various phenomena under three broad categories, like (a) clinical--Meyerson, Meirowsky, pathergy, Renbok, (b) laboratory--LE cell, prozone and (c) histopathology--Splendore-Hoeppli.

Intradermal tests in dermatology-I: Tests for infectious diseases

INTRODUCTION Although the tests could be done at any site, the proximal part of the flexor aspect of the forearm is Intradermal tests are widely used to support the conventionally used. This site can be conveniently diagnosis of dermatological and nondermatological exposed and the skin of the proximal area is more diseases. They are mainly indicated for the detection sensitive than the distal. of immediate (Type I hypersensitivity) and delayed type hypersensitivity (DTH, Type IV hypersensitivity) INTERPRETATION OF INTRADERMAL TESTS towards exogenous or endogenous antigens. Intradermal tests for the diagnosis of infectious The optimal time for reading the reaction depends diseases in relevance to dermatovenereology are upon the pharmacological agent used for the test discussed in this section. and the type of immunological reaction to be observed. Intradermal tests for the detection of DTH Intradermal tests for the diagnosis of infectious are read at 48h, although they can be read as early diseases are listed in Table 1. They are indicated to as 12h and as late as four days. (The lepromin test detect DTH to organisms or their antigens. is read at four weeks and depends on the formation of a granuloma, which is a measure of cell-mediated Before undertaking intradermal test, it is advisable to immunity.) The size of the induration is more stop or avoid systemic steroids or immunosuppressive important than erythema while interpreting Type agents at least three days before the procedure as IV hypersensitivity. moderate to large doses of corticosteroids may inhibit a DTH reaction.

Secukinumab efficacy and safety in indian patients with moderate-to-severe plaque psoriasis: Sub-analysis from FIXTURE, a randomized, placebo-controlled, phase 3 study

Title: Secukinumab efficacy and safety in Indian patients with moderate-to-severe plaque psoriasis: sub-analysis from FIXTURE (Full Year Investigative Examination of Secukinumab vs. Etanercept Using Two Dosing Regimens to Determine Efficacy in Psoriasis), a randomized, placebo-controlled, phase 3 study. Background: Evidence has suggested Interleukin (IL)-17A to be an important effector cytokine in the pathogenesis of psoriasis. Here, we report results for an Indian sub-population from a multinational study FIXTURE, designed to assess the safety, tolerability, and long-term efficacy of fully human anti–IL-17A monoclonal antibody secukinumab in patients with moderate-to-severe plaque psoriasis. Materials and Methods: In this double-dummy, placebo controlled, 52-weeks phase 3 study FIXTURE, 149 Indian patients were randomized 1:1:1:1 to receive secukinumab at a dose of 300 mg or 150 mg, etanercept, or placebo. The study objective was to show the superiority of secukinumab over placebo at week 12, vis-à-vis proportion of patients achieving a reduction of 75% or more from the baseline in the psoriasis area-and-severity index score (PASI 75) and a score of 0 (clear) or 1 (almost clear) on a 5-point modified investigators global assessment (IGA mod 2011) (co-primary end points). Results: At week 12, 61.0% and 55.9% patients in secukinumab 300 mg and 150 mg groups, respectively, achieved PASI 75 response compared to 20.0% in the etanercept and 7.1% in the placebo groups. Similarly, IGA mod 2011 0 or 1 response was achieved by 43.9% and 20.6% in patients in the secukinumab 300 mg and 150 mg group, respectively, vs. 13.3% in the etanercept and 2.4% in the placebo groups at week 12. Likewise, higher proportions of patients in secukinumab 300 mg (41.5%) and 150 mg (20.6%) group were PASI 90 responders at week 12 than those in the etanercept (10.0%) or placebo (0.0%) groups. The incidences of adverse events (AEs), during the induction period were similar in all the treatment groups. Overall secukinumab was well-tolerated at both doses in the Indian sub-population. Conclusion: The results from the Indian sub-population suggest that secukinumab is an efficacious and safe drug for use in moderate-to-severe chronic plaque psoriasis

Guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis: An Indian perspective.

Background: Stevens–Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous adverse drug reactions with a high morbidity and mortality that require immediate medical care. The various immunomodulatory treatments include systemic corticosteroids, cyclosporine, intravenous immunoglobulin, cyclophosphamide, plasmapheresis and tumor necrosis factor-α inhibitors. Aim: The ideal therapy of Stevens–Johnson syndrome/toxic epidermal necrolysis still remains a matter of debate as there are only a limited number of studies of good quality comparing the usefulness of different specific treatments. The aim of this article is to comprehensively review the published medical literature and frame management guidelines suitable in the Indian perspective. Methods: The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) assigned the task of preparing these guidelines to its special interest group on cutaneous adverse drug reactions. The group performed a comprehensive English language literature search for management options in Stevens–Johnson syndrome/toxic epidermal necrolysis across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for keywords (alone and in combination) and MeSH items such as “guidelines,” “Stevens–Johnson syndrome,” “toxic epidermal necrolysis,” “corticosteroids,” “intravenous immunoglobulin,” “cyclosporine” and “management.” The available evidence was evaluated using the strength of recommendation taxonomy and graded using a three-point scale. A draft of clinical recommendations was developed on the best available evidence which was also scrutinized and critically evaluated by the IADVL Academy of Dermatology. Based on the inputs received, this final consensus statement was prepared. Results: A total of 104 articles (meta-analyses, prospective and retrospective studies, reviews [including chapters in books], previous guidelines [including Indian guidelines of 2006] and case series) were critically evaluated and the evidence thus gathered was used in the preparation of these guidelines. Recommendations: This expert group recommends prompt withdrawal of the culprit drug, meticulous supportive care, and judicious and early (preferably within 72 h) initiation of moderate to high doses of oral or parenteral corticosteroids (prednisolone 1-2 mg/kg/day or equivalent), tapered rapidly within 7-10 days. Cyclosporine (3-5 mg/kg/day) for 10-14 days may also be used either alone, or in combination with corticosteroids. Owing to the systemic nature of the disease, a multidisciplinary approach in the management of these patients is helpful.

Generalized bullous fixed drug reaction: A close similarity to stevens–johnson syndrome

Generalized bullous fixed drug eruption is bullous type of fixed drug eruption characterized by sharply defined bullae at the same site following administration of offending drug. GBFDE has aggressive course unlike conventional FDE and requires aggressive treatment. Mucosa is usually spared and constitutional symptoms are mild. We came across two cases of GBFDE in which culprit drugs were B-Lactam antibiotics.

Clinical profile of cutaneous manifestations with and without hematologic disease: A comparative study.

Aim: The aim was to study the clinical profile of cutaneous manifestations of hematologic disorders and to compare it with that of non-hematologic disorders. Materials and Methods: Cutaneous manifestations of hematologic diseases fall in seven well-defined categories. A total of 153 outpatients with skin manifestations fitting in these categories were enrolled in a comparative study of 1-year duration. Clinical profile of these cutaneous manifestations was studied and any underlying hematologic disorder was ruled out with the help of a hematologist. Difference in the clinical profile of cutaneous manifestations with and without hematologic diseases was studied. Result: Of the 26,174 outpatients during the study period, 153 had cutaneous manifestations fitting in the categories of hematologic disorders. Of these 153 patients, 33 had hematologic disease as the cause of their cutaneous manifestation (21.57%), whereas 78.42% had no hematologic disorder. Disorders of hemostasis formed the largest group (36%) followed by cutaneous deposits/infiltrations (15%), vesiculobullous disorders (6%), and cutaneous vasculitis (9%) were least commonly associated with hematologic disorders. Conclusion: Hematologic diseases are associated with complex array of cutaneous manifestations. The incidence of hematologic disease–associated cutaneous manifestations was 0.13%. Findings of this study will help dermatologists and physicians with the early recognition of cutaneous signs of hematologic disorders.

Confocal laser microscope

The confocal laser microscope is a novel and interesting noninvasive tool for imaging skin lesions and subsurface skin lesions that are not visible to the naked eye or even by dermoscopy. Skin can be imaged in vivo or freshly biopsied (in vitro) skin specimens can be visualized immediately without the processing that is required for routine histopathology. Dynamic events (real time imaging) in the epidermis, papillary dermis and superficial reticular dermis to a maximum depth of 350 μm below the stratum corneum can also be visualized. It has potential for diagnosing skin lesions with precision and could also become a tool for monitoring treatments in some cases.

Managing a side effect: Cyclosporine-Induced nephrotoxicity

intrODuCtiOn Cyclosporine (CsA), an immunosuppressant, is a calcineurin inhibitor (CNI) which is specific for T-cells. It was discovered in Sandoz Laboratories in Basel, Switzerland by isolating it from the soil fungus Tolypocladium inflatum gams.[1] Initially used for rheumatoid and psoriatic arthritis, it was later approved for prophylaxis of organ rejection. Dermatologists often prescribe CsA in the dose of 3–5 mg/ kg/day for management of papulosquamous disorders, mainly psoriasis and autoimmune connective tissue disorders. It is also used off-label in atopic dermatitis. Nowadays, CsA is increasingly being used for the treatment of toxic epidermal necrolysis with good effects. Calne et al. used CsA following transplantation in a dose of 25 mg/kg and found unexpected nephrotoxicity that had previously not been seen in animal experiments.[2] Most of the persistent renal dysfunction is seen when the drug is used for a long duration of time and when dose of CsA is >5 mg/kg/day, especially in patients of psoriasis. This is an important side effect that needs to be recognized at early stages to avoid chronic kidney damage or irreversible nephrotoxicity.