Vijay K Garg

Antibiotic resistance to Propionobacterium acnes: worldwide scenario, diagnosis and management

Antibiotic resistance in cutaneous Propionobacterium is a global problem. As a general rule, resistance levels are high to macrolides, trimethoprim/sulfamethoxazole and clindamycin, while tetracyclines and levofloxacin have low resistance potential. Newer preparations like doxycycline MR and doxycycline 20 mg are subantimicrobial and may not lead to resistance. Sampling techniques are crucial to determine resistance. Genomic evaluation using 16S ribosomal RNA gene sequencing can be useful in diagnosing mutations and mapping phylotypes of Propionobacterium acnes. Resistance may lead to slow response and relapses. Apart from benzoyl peroxide, azelaic acid, topical dapsone, oral zinc and retinoids, novel molecules with little resistance potential include octadecenedioic acid, phytosphingosine, lauric acid, retapamulin, resveratrol, T-3912 and NB-003. The use of oral retinoids and non-antibiotics like zinc can prevent resistance and help reduce the dependence on antibiotics.

Rising trend of antimicrobial resistance among Neisseria gonorrhoeae isolates and the emergence of N. gonorrhoeae isolate with decreased susceptibility to ceftriaxone.

Context: Gonorrhoea is one of the most common sexually transmitted infections (STI) in developing countries and is a global health problem. Aims: To analyze the trend of antimicrobial susceptibility of Neisseria gonorrhoeae isolates over the years, in a tertiary care hospital of North India. Settings and Design: The study population comprised males with urethritis and females with endocervicitis attending STI clinic of our hospital. Materials and Methods: In our STI laboratory, all gonococcal isolates are subjected to antimicrobial susceptibility testing by disc diffusion method as per CLSI guidelines. β-lactamase production is determined by chromogenic cephalosporin test. Minimum Inhibitory Concentration (MIC) for ceftriaxone is determined by E-test. Statistical Analysis Used: Data were expressed as percentages. The differences in percentages were tested for statistical significance by using χ2 test and P values were determined. Results: The percentage of penicillinase producing N. gonorrhoeae (PPNG) increased from 8% in 1995-96 to 20% in 2004-05 and 88% in 2011-2013. Quinolone-resistant N. gonorrhoeae (QRNG) showed a significant increase from 12% in 1995-96 to 98.3% in 2004-05, while 84% isolates were found to be QRNG by 2011-2013. In January 2013 we detected our first gonococcal isolate with decreased susceptibility to third-generation cephalosporins; Ceftriaxone, Cefixime and Cefpodoxime (MIC for ceftriaxone = 0.19 μg/ml). Conclusions: The results of our study highlighted an alarming increase in the percentage of PPNG and QRNG strains over the years. Emergence of N. gonorrhoeae isolates with decreased susceptibility to third-generation cephalosporins is a cause of concern and thus emphasises the importance of antimicrobial susceptibility testing.

Vitamin D and skin diseases: A review.

Vitamin D, originally associated with rickets and osteomalacia, has recently been shown to have a role in a number of medical and dermatological diseases. It has been found that vitamin D receptors and the enzymatic machinery capable of converting circulating 25-hydroxyvitamin D [25(OH)D] to the active 1,25-hydroxyvitamin D [1,25(OH)D] is present in most cells in the body including the skin. It is well known that vitamin D analogs are effective in the treatment of psoriasis vulgaris because of their anti-proliferative and pro-differentiating effects on keratinocytes. However, new roles have been found for vitamin D in skin, such as immunomodulatory and anti-apoptotic effects thus raising a possibility of its use in conditions such as atopic dermatitis and infections. Increasing evidence now indicates that cutaneous vitamin D synthesis may help in prevention of skin malignancies and further, that cancer mortality may be reduced by oral supplementation of vitamin D. Various epidemiological studies have linked low levels of vitamin D to autoimmune diseases including vitiligo, and topical vitamin D has been used to treat vitiligo. This review focuses on a wide array of roles of vitamin D in various skin disorders with emphasis on both its well-established role as in psoriasis and the less characterized role in other disorders such as ichthyosis, tuberculosis or acne.

Immunomodulators in warts: Unexplored or ineffective?

Cutaneous warts are known to be recurrent and often resistant to therapy. Resistant warts may reflect a localized or systemic cell mediated immune (CMI) deficiency to HPV. Many modalities of treatment are in use; most of the provider-administered therapies are destructive and cause scarring, such as cryotherapy, chemical cauterisation, curettage, electrodessication and laser removal. Most patient-applied agents like podophyllotoxin have the risk of application-site reactions and recurrence. Thus immunotherapy is a promising modality which could lead to resolution of warts without any physical changes or scarring and in addition would augment the host response against the causative agent, thereby leading to complete resolution and decreased recurrences. Immunomodulators can be administered systemically, intralesionally or intradermally, and topically. A few agents have been tried and studied extensively such as cimetidine and interferons; others are new on the horizon, such as Echinacea, green tea catechins and quadrivalent HPV vaccine, and their efficacy is yet to be completely established. Though some like levamisole have shown no efficacy as monotherapy and are now used only in combination, other more recent agents require large and long term randomized placebo-controlled trials to clearly establish their efficacy or lack of it. In this review, we focus on the immunomodulators that have been used for the treatment of warts and the studies that have been conducted on them.

A clinicotherapeutic analysis of Stevens–Johnson syndrome and toxic epidermal necrolysis with an emphasis on the predictive value and accuracy of SCORe of Toxic Epidermal Necrolysis

The SCORTEN scale (SCORe of Toxic Epidermal Necrolysis) is widely used to predict mortality in patients with Stevens–Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Although it is largely a useful tool, the predictive ability of the scale is variable, and modifications to the existing scale have been suggested. In addition, there is controversy regarding the roles of active therapy and conservative management.

A rapid tattoo removal technique using a combination of pulsed Er:YAG and Q-Switched Nd:YAG in a split lesion protocol.

Abstract Background: Tattoo removal has evolved over the years and though Q-switched laser is the ‘workhorse’ laser, it invariably requires multiple sittings, which are dependent on numerous factors, including the skin colour, location of the tattoo, age of the tattoo, colour of pigment used, associated fibrosis and the kind of tattoo treated. Though ablative lasers, both pulsed CO2 and Er:YAG, have been used for recalcitrant tattoos, very few studies have been done comparing them with pigment-specific lasers. Our study was based on the premise that ablating the epidermis overlying the tattoo pigment with Er:YAG could help in gaining better access to the pigment which would enable the Q-switched laser to work effectively with less beam scattering. Objective: A study of rapid tattoo removal (RTR) technique using a combination of pulsed Er:YAG and Q-Switched Nd:YAG in a split lesion protocol. Materials and methods: This prospective study was undertaken during 2010–13 at a laser Clinic in the Maulana Azad Medical College, New Delhi. A total of 10 patients were recruited, 5 of amateur tattoo and 5 of professional tattoo. After informed consent each tattoo was arbitrarily ‘split’ into two parts. One part was treated with QS Nd:YAG laser(1064 nm) and the other part with Er:YAG laser immediately followed by the QS Nd:YAG. The laser treatments were repeated at 6-week intervals until the tattoo pigment had cleared. On the combination side in subsequent sittings only the QS Nd:YAG was used, to minimize repetitive ablation. To ensure consistency in the intervention methods a trained dermatologist who was independent of the treatment delivery randomly rated 10% of the procedures. Results: The mean improvement achieved by the Q-switched laser (2.93) was less than the combination laser (3.85) side (p = 0.001) and needed more sessions (3.8 vs. 1.6; p = 0.001). There was a statistically significant difference in the improvement on the combination side till the second session. On the combination side patients required a maximum of 2 sessions, while the Q-switched laser required 3–5 sessions for appreciable lightening. Conclusion: From our study it was concluded that use of a pulsed ablative laser may help in rapid removal of tattoos in conjunction with QS lasers with minimal side effects and can be used as a RTR.

A prospective study comparing ultrapulse CO2 laser and trichloroacetic acid in treatment of Xanthelasma palpebrarum.

Xanthelasma Palpebrarum is a type of xanthoma which presents as cosmetic concern.

Role of serum interleukin-6 in deciding therapy for multidrug resistant oral lichen planus.

Background Oral lichen planus (OLP) is a T cell mediated immune response. T cells locally present in the involved tissues release cytokines like interleukin-6 (IL-6), which contributes to pathogenesis of OLP. Also IL-6 has been associated with multidrug resistance protein (MRP) expression by keratinocytes. Correspondingly, upregulation of MRP was found in OLP. We conducted this study to evaluate the effects of various drugs on serum IL-6 in OLP; and correlation of these effects with the nature of clinical response and resistance pattern seen in OLP lesions with various therapeutic modalities. Thus we evaluated the role of serum IL-6 in deciding therapy for multidrug resistant OLP. Material and Methods Serum IL-6 was evaluated in 42 erosive OLP (EOLP) patients and 10 normal mucosa and 10 oral squamous cell carcinoma cases using ELISA technique. OLP patients were randomly divided into 3 groups of 14 patients each and were subjected to Pimecrolimus local application, oral Mycophenolate Mofetil (MMF) and Methotrexate (MTX) alongwith Pimecrolimus local application. IL-6 levels were evaluated before and after treatment. Results Serum IL-6 levels were raised above 3pg/ml in 26.19% erosive OLP (EOLP) cases (mean- 3.72±8.14). EOLP (5%) cases with IL-6 levels above 5pg/ml were resistant in MTX group. However significant decrease in serum IL-6 corresponding with the clinical resolution was seen in MMF group. Conclusions Significantly raised IL-6 levels in EOLP reflect the chronic inflammatory nature of the disease. As serum IL-6 levels significantly decreased in MMF group, correspondingly no resistance to treatment was noted. However with MTX there was no significant decrease in IL-6 and resistance to treatment was noted in some, especially plaque type lesions. Thus IL-6 can be a possible biomarker in deciding the best possible therapy for treatment resistant OLP. Key words:Lichen planus, biological markers, cytokines, enzyme-linked immunosorbent assay, immunosuppressive agents.

Acquired port-wine stain in an adult male: First reported case from India with review of literature

Port-wine stains (PWSs) are congenital vascular lesions caused by progressive ectasia of blood vessels located in the vascular plexus of the dermis. Acquired PWSs develop later in life but are identical in morphology and histology to the congenital PWSs. Less than 75 cases of acquired PWSs have been reported in the published literature, of which there has not been a single report from India so far. Various factors have been proposed for its pathogenesis like trauma, actinic exposure, drugs, tumors, and herpes zoster infection. We report an acquired port-wine stain in a 41-year-old male. The causative factors, treatment, and previous reports of this uncommon entity have also been reviewed.

Solitary eccrine syringofibroadenoma with nail involvement: A rare entity

Eccrine syringofibroadenoma (ESFA) is a rare, benign tumor of eccrine sweat gland origin that usually presents as a nodule on the extremities of an elderly person. It can also present as an ulcerative plaque, verrucous lesion, papular or nodular lesion or as palmoplantar keratoderma. Although the clinical features are variable, histology is characteristic in the form of anastomosing strands, cords and columns of epithelial cells embedded in a fibrovascular stroma. We report the case of a 62-year-old male with a nodular lesion on the extremity that caused secondary involvement of the nail in the form of complete nail dystrophy. The histology showed features consistent with ESFA. Nail involvement by ESFA is a rare presentation and is rarely described in the literature.