Uday Khopkar

Improving adherence to antiretroviral therapy.

Antiretroviral therapy (ART) has transformed HIV infection into a treatable, chronic condition. However, the need to continue treatment for decades rather than years, calls for a long-term perspective of ART. Adherence to the regimen is essential for successful treatment and sustained viral control. Studies have indicated that at least 95% adherence to ART regimens is optimal. It has been demonstrated that a 10% higher level of adherence results in a 21% reduction in disease progression. The various factors affecting success of ART are social aspects like motivation to begin therapy, ability to adhere to therapy, lifestyle pattern, financial support, family support, pros and cons of starting therapy and pharmacological aspects like tolerability of the regimen, availability of the drugs. Also, the regimens pill burden, dosing frequency, food requirements, convenience, toxicity and drug interaction profile compared with other regimens are to be considered before starting ART. The lack of trust between clinician and patient, active drug and alcohol use, active mental illness (e.g. depression), lack of patient education and inability of patients to identify their medications, lack of reliable access to primary medical care or medication are considered to be predictors of inadequate adherence. Interventions at various levels, viz. patient level, medication level, healthcare level and community level, boost adherence and overall outcome of ART.

Type I lepra reaction presenting as immune reconstitution inflammatory syndrome.

Immune reconstitution inflammatory syndrome (IRIS) is an unusual inflammatory reaction due to infectious and non-infectious causes occurring in human Immunodeficiency virus (HIV)-infected patients. IRIS occurs after the initiation of antiretroviral therapy. There are no reports of type I lepra reaction due to IRIS in published literature from India. We report two cases of HIV-infected males who presented with borderline tuberculoid leprosy in type 1 reaction after the initiation of highly active antiretroviral treatment (HAART). Case 1 presented with multiple, tender, erythematous and hypoesthetic plaques on the trunk and extremities after 3 months of antiretroviral therapy. In case 2, type I lepra reaction was observed 2 months after the initiation of HAART.

Trichoscopy in alopecias: Diagnosis simplified

Trichoscopy is the term coined for dermoscopic imaging of the scalp and hair. This novel diagnostic technique, both simple and non-invasive, can be used as a handy bed side tool for diagnosing common hair and scalp disorders. Trichoscopic observations can be broadly grouped as hair signs, vascular patterns, pigment patterns and interfollicular patterns. In this article, we have briefly described the trichoscopic findings in the common categories of cicatricial and non-cicatricial alopecias such as androgenetic alopecia, alopecia areata, telogen effluvium, tinea capitis, trichotillomania, lichen planopilaris, discoid lupus erythematosus and hair shaft disorders. Besides diagnosing alopecia, it has the potential for obviating unnecessary biopsies and when a biopsy is still needed it is helpful in choosing an ideal biopsy site. Moreover, trichoscopy is a valuable tool for evaluating the treatment response photographically at each follow-up. The last statement here is deleted as asked.

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.

Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in community-acquired primary pyoderma.

BACKGROUND Although prevalence of MRSA strains is reported to be increasing, there are no studies of their prevalence in community-acquired primary pyodermas in western India. AIMS This study aimed at determining the prevalence of MRSA infection in community-acquired primary pyodermas. METHODS Open, prospective survey carried out in a tertiary care hospital in Mumbai. MATERIALS AND METHODS Eighty-six patients with primary pyoderma, visiting the dermatology outpatient, were studied clinically and microbiologically. Sensitivity testing was done for vancomycin, sisomycin, gentamicin, framycetin, erythromycin, methicillin, cefazolin, cefuroxime, penicillin G and ciprofloxacin. Phage typing was done for MRSA positive strains. RESULTS The culture positivity rate was 83.7%. Staphylococcus aureus was isolated in all cases except two. Barring one, all strains of Staphylococcus were sensitive to methicillin. CONCLUSIONS Methicillin resistance is uncommon in community-acquired primary pyodermas in Mumbai. Treatment with antibacterials active against MRSA is probably unwarranted for community-acquired primary pyodermas.

WEARY‐KINDLER SYNDROME WITH MULTIPLE SEBORRHEIC KERATOSES

A 20-year-old housewife born of a consanguineous marriage presented with dark patches and rough raised lesions all over the body since the age of 5 years. The patient noticed a gradual increase in size and extent of these lesions. On inquiry there was a history of photosensitivity, slowly progressive hair loss for 10 years, and oral lesions for 6 months. There was a history of self-healing fluid-filled skin lesions from the age of 5 years, which subsided on their own at the age of 12 years. Pigmentation or hair loss were not preceded by skin lesions. The patients menstrual and obstetric history was normal. On examination she was 5 feet tall, weighting 39 kg, and with normal intelligence. Skin examination revealed hypoand hyperpigmentation, atrophy, and telangiectasia over the neck, upper chest, shoulders, and lips indicating poikiloderma (Fig. 1). She had multiple rough brown to black hyperpigmented patches, keratotic papules, and plaques, 0.5 to 5 cm in size, on the scalp, face, neck, trunk (Figs. 1 and 2), flexures, and extremities, as well as the palms and soles where they resembled palmoplantar warts. The scalp showed cicatricial alopecia. The skin of the face and the dorsa of the hands and feet was shiny and atrophic. Tips of the fingers and toes showed soft tissue absorption. Erosion of the hard palate and hyperpigmentation of the vermilion of the lips was noted. Dystrophy was observed in all finger nails. Slit-lamp and fundoscopy of the eyes was normal. Hearing was unimpaired. The following laboratory investigations were normal: urine and stool analysis, hemoglobin, leukocyte count total/ differential, erythrocyte sedimentation rate, serum proteins, blood urea nitrogen, serum creatinine, blood sugars fasting/post-prandial. X-rays of hands and chest were normal. Biopsy of a keratosis showed hyperkeratosis, hypergranulosis, papillomatosis, and acanthosis giving a church spire appearance (Fig. 3). These changes were consistent with hyperkeratotic seborrheic keratosis. Biopsy of neck lesions showed atrophic epidermis and basal cell degeneration. The dermis showed melanin incontinence, dilated capillaries, and sparse perivascular mononuclear infiltrate. Biopsy from the skin of the dorsum of the hand revealed atrophic epidermis, hyalinization of collagen and sparse perivascular lymphohistiocytic infiltrate in the dermis. The patient was advised photoprotection and regular follow up.

Disseminated cutaneous histoplasmosis in an immunocompetent adult.

Histoplasmosis, a systemic mycosis caused by the dimorphic fungus Histoplasma capsulatum var capsulatum and Histoplasma capsulatum var duboisii is endemic to many parts of the world. The clinical manifestations range from acute or chronic pulmonary infection to a progressive disseminated disease. After initial exposure to the fungus, the infection is self-limited and restricted to the lungs in 99% of healthy individuals. The remaining 1%, however, progress to either disseminated or chronic disease involving the lungs, liver, spleen, lymph nodes, bone marrow or rarely, the skin and mucous membranes. Mucocutaneous histoplasmosis is frequently reported in patients with acquired immune deficiency syndrome (AIDS), but it is rare in immunocompetent hosts. A 60-year-old male presented with asymptomatic swelling of the hard palate and crusted papules and nodules over the extremities, face and trunk. Clinically, the diagnoses of cutaneous cryptococcosis versus histoplasmosis was considered in this patient. A chest X-ray revealed hilar lymphadenopathy. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was nonreactive. Skin biopsy revealed multiple tiny intracellular round yeast forms with a halo in the mid-dermis. Culture of the skin biopsy in Sabourauds dextrose agar showed colonies of Histoplasma capsulatum. Despite an investigation including no evidence of underlying immunosuppression was found, he was started on IV amphotericin-B (0.5 mg/kg/day). However, the patient succumbed to his disease 2 days after presentation. We report a rare case of disseminated cutaneous histoplasmosis in an immunocompetent individual.

A study of clinicopathologic profile of 15 cases of hypopigmented mycosis fungoides.

BACKGROUND Mycosis fungoides (MF) is cutaneous lymphoma of the T-cell lineage. Hypopigmented MF is a clinical variant of MF, described mainly in Asians. This is a retrospective clinicopathologic analysis of hypopigmented MF at a tertiary care center. AIMS To describe the clinicopathologic profile of hypopigmented MF. METHODS Records of clinicopathologic notes over a 5-year period ranging from January 2005 up to December 2009 were reviewed over a period of 3 months, of which 15 cases were diagnosed with hypopigmented MF based on clinicopathologic correlation. RESULTS Hypopigmented MF was found to be more common in males, and between second and fourth decades of life. The latent period between onset and diagnosis was around 3.83 years. Most of the patients were asymptomatic 80% (12/15), with skin changes of subtle atrophy in 46.66% (7/15), scaling in 20% (3/15) and focal changes of poikiloderma in 26.66% (4/15) patients. Most common sites of distribution of the lesions were the trunk and extremities. Many of the cases had been clinically mistaken for Hansens disease prior to correct diagnosis. Marked epidermotropism and tagging of epidermis by large lymphocytes characterizes the condition histopathologically. Of the 15 cases, immunohistochemistry was possible in 10 cases, of which 8 showed predominant CD8 positive epidermotropic infiltrates and two cases showed absence of CD8 positive and CD4 positive lymphocytic infiltrate in the epidermis. CONCLUSION Hypopigmented MF presents as hypopigmented asymptomatic patches without any erythema or infiltration in its early stage and mimics Hansens disease. Skin biopsy clinches the diagnosis.

Monilethrix in pattern distribution in siblings: Diagnosis by trichoscopy

Monilethrix is a heritable hair shaft defect characterized by localized or diffuse alopecia resulting from hair fragility over friction areas, predominantly the temporal and occipital regions, and follicular keratosis over the occipital region. However, it lacks macroscopic features that enable easy and rapid diagnosis in medical practice. Hair shaft microscopy is the basis for diagnosing monilethrix. We present a report of two Indian male siblings aged 24 and 21, who presented with thinning and hair loss from the scalp in male pattern distribution and multiple skin-colored follicular papules over the nape of the neck and bilateral forearms since childhood. Trichoscopy of scalp hair revealed characteristic uniform elliptical nodes and intermittent constrictions along with variation in hair shaft diameter, presence of few vellus hair and yellow dots, suggesting a diagnosis of monilethrix with early-onset androgenetic alopecia. Dermoscopy of the papules revealed multiple stubs of broken hair arising from them with a similar beaded appearance, suggesting a diagnosis of monilethrix. The diagnosis of monilethrix was confirmed with light microscopy and hair clipping. This report highlights the patterned distribution of hair loss in monilethrix probably due to the early unmasking of androgenetic alopecia and the use of trichoscopy as the diagnostic modality.

An approach to the diagnosis of neutrophilic dermatoses: A histopathological perspective

Neutrophilic dermatoses comprises of non-infective dermatoses which are histopathologically characterized by neutrophil predominant infiltrate and clinically, respond promptly to corticsteroids. Conditions primarily with vasculitis though neutrophilic are excluded from this group. In this article we intend to briefly outline the approach to diagnose these conditions with histological perspective. The ambiguity regarding few recent dermatosis viz, rheumatoid neutrophilic dermatosis, bowel associated-dermatosis-arthritis syndrome etc. with regard to their inclusion in this group has also been highlighted.