Vijay Zawar

Pityriasis rosea--an update.

Recent controversies on the etiology, diagnosis and treatment have led to increased interest in pityriasis rosea (PR). We review these aspects of the disease. PR is universal. The incidence is around 0.68 per 100 dermatological patients, or 172.2 per 100,000 person-years. The prevalence in people aged between 10 and 29 years is 0.6%. The male to female ratio is around 1:1.43. Evidence on seasonal variation is conflicting, but there is no evidence that the incidence is dependent on mean air temperature, mean total rainfall, or mean relative humidity. Spatial-temporal and temporal clustering of cases of PR has been reported. The association of PR with human herpesvirus-7 infection is still controversial. Owing to the extreme high sensitivities of sequence-based detection methods such as polymerase chain reaction, novel criteria should be applied to evaluate the evidence. There is no evidence that PR is associated with other viral or bacterial infections. The role of autoimmunity in PR warrants further investigations. Many patients with PR have one or more atypical features. Application of validated diagnostic criteria may be helpful for atypical cases. The efficacy of macrolides, including erythromycin, in PR is still under evaluation. There is no evidence that antiviral agents are effective. The efficacies of ultraviolet radiotherapy and systemic corticosteroids are not well established. In managing a patient with PR, we should concentrate more on how the eruption is affecting the quality of life, i.e. the illness, rather than the extent and severity of the eruption, i.e. the disease.

Is human herpesvirus 7 the causative agent of pityriasis rosea?--A critical review.

Background  Conflicting results on the association of pityriasis rosea and human herpesvirus 7 infection have been reported by different investigators.

Fixed drug eruption: a sexually inducible reaction?

We present three cases of diagnosed fixed drug eruption (FDE) in male patients with known drug sensitivity. In each case, the patient has refrained strictly from intake of the offending agent over many years. FDE developed after history of sexual contact with their spouses who were found to be receiving the same medication to which their partners were hypersensitive. We hypothesized that sexual transfer of the drug antigen occurs through the vaginal fluid on the sensitized area of the male genitalia.

The Diagnostic Criteria of Gianotti-Crosti Syndrome: Are They Applicable to Children in India?

Abstract:  In order to evaluate the applicability of the diagnostic criteria to children with Gianotti‐Crosti syndrome (GCS) in India we retrieved all clinical records of children with a definite diagnosis of this syndrome seen over 30 months in a private dermatology practice. The controls were children for whom Gianotti‐Crosti had been suspected but the final diagnosis was not this syndrome, and children in whom it was not suspected but who were diagnosed with any of the differential diagnoses of the syndrome. We documented the presence or absence of the positive and negative clinical features for all patients and controls. The clinical records of 23 children with GCS and 74 controls were retrieved. The three positive clinical features – 1) papules or papulovesicles 1–10 mm in diameter on at least three of the following four sites: cheeks, buttocks, extensor surfaces of the forearms, extensor surfaces of legs; 2) being symmetrical; 3) lasting for at least 10 days – were sensitive and positively correlated with GCS. Both negative clinical features – extensive truncal lesions and scaly lesions – are negatively correlated with this syndrome. All 23 children with GCS and none of the controls fulfilled the set of diagnostic criteria. We concluded that the Gianotti‐Crosti diagnostic criteria are applicable to affected children in India.

Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, unilateral mediothoracic exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome: a brief review and arguments for diagnostic criteria

Several exanthems including Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome are suspected to be caused by viruses. These viruses are potentially dangerous. Gianotti-Crosti syndrome is related to hepatitis B virus infection which is the commonest cause of hepatocellular carcinoma, and Epstein-Barr virus infection which is related to nasopharyngeal carcinoma. Pityriasis rosea has been suspected to be related to human herpesvirus 7 and 8 infections, with the significance of the former still largely unknown, and the latter being a known cause of Kaposis sarcoma. Papular-purpuric gloves and socks syndrome is significantly associated with human B19 erythrovirus infection which can lead to aplastic anemia in individuals with congenital hemoglobinopathies, and when transmitted to pregnant women, can cause spontaneous abortions and congenital anomalies. With viral DNA sequence detection technologies, false positive results are common. We can no longer apply Kochs postulates to establish cause-effect relationships. Biological properties of some viruses including lifelong latent infection, asymptomatic shedding, and endogenous reactivation render virological results on various body tissues difficult to interpret. We might not be able to confirm or refute viral causes for these rashes in the near future. Owing to the relatively small number of patients, virological and epidemiology studies, and treatment trials usually recruit few study and control subjects. This leads to low statistical powers and thus results have little clinical significance. Moreover, studies with few patients are less likely to be accepted by mainstream dermatology journals, leading to publication bias. Aggregation of data by meta-analyses on many studies each with a small number of patients can theoretically elevate the power of the results. Techniques are also in place to compensate for publication bias. However, these are not currently feasible owing to different inclusion and exclusion criteria in clinical studies and treatment trials. The diagnoses of these rashes are based on clinical assessment. Investigations only serve to exclude important differential diagnoses. A wide spectrum of clinical features is seen, and clinical features can vary across different populations. The terminologies used to define these rashes are confusing, and even more so are the atypical forms and variants. Previously reported virological and epidemiological results for these rashes are conflicting in many aspects. The cause of such incongruence is unknown, but low homogeneity during diagnosis and subject recruitment might be one of the factors leading to these incongruent results. The establishment and proper validation of diagnostic criteria will facilitate clinical diagnosis, hasten recruitment into clinical studies, and allow results of different studies to be directly compared with each another. Meta-analyses and systematic reviews would be more valid. Diagnostic criteria also streamline clinical audits and surveillance of these diseases from community perspectives. However, over-dependence on diagnostic criteria in the face of conflicting clinical features is a potential pitfall. Clinical acumen and the experience of the clinicians cannot be replaced by diagnostic criteria. Diagnostic criteria should be validated and re-validated in response to the ever-changing manifestations of these intriguing rashes. We advocate the establishment and validation of diagnostic criteria of these rashes. We also encourage the ongoing conduction of studies with a small number of patients. However, for a wider purpose, these studies should recruit homogenous patient groups with a view towards future data aggregation.

Epiluminescence dermatoscopy enhanced patient compliance and achieved treatment success in pseudofolliculitis barbae

A patient presented with recalcitrant pseudofolliculitis barbae and hypertrophic scarring. The use of epiluminescence dermatoscopy rendered clear visualization of U‐shaped ingrowing hairs corresponding to the sites of individual papules. Such real‐time demonstration led to an attitude change and good compliance with medical advice against overshaving, resulting in a successful treatment outcome.

Pityriasis rosea-like eruptions due to mustard oil application.

A young man employed in a construction company, presented with cutaneous lesions clinically simulating pityriasis rosea. Satisfactory and complete response to corticosteroids and antihistamines was followed by recurrence. Multiple recurrences within a short span of time arose a suspicion of alternative diagnosis. Site visit helped us to rule out occupational contact dermatitis. Further history taking revealed that he was recently using mustard oil for body massage. Subsequent patch testing confirmed contact hypersensitivity to mustard oil. Avoidance of the contact with mustard oil arrested appearance of further skin lesions. We stress the importance of taking a good history in clinical practice in disclosing a possible contactant.

Follicular pityriasis rosea. A case report and a new classification of clinical variants of the disease.

BACKGROUND Atypical forms of pityriasis rosea are often noticed in Indian children. MAIN OBSERVATIONS We describe a 9-year-old male child with predominant follicular eruptions on trunk consistent with a clinical diagnosis of pityriasis rosea. CONCLUSION Follicular pityriasis rosea is an extremely rare presentation of the disease. We propose a new classification of clinical variants of pityriasis rosea.

Consensus statement on the management of urticaria.

This consensus statement was developed by Special Interest Group – Urticaria (IADVL). Urticaria, a heterogeneous group of diseases, often cannot be recognized by its morphology. Due to non-specific and non-affordable diagnosis, management of urticaria, especially chronic urticaria, is very challenging. This guideline includes definition, causes, classification and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is identification and elimination of the underlying cause(s) and/or eliciting trigger(s), while the second one is treatment aimed at providing symptomatic relief. This guideline recommends use of second-generation non-sedating H1 antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the cost.

Erythema multiforme-like lesions in the course of infectious mononucleosis.

BACKGROUND The rash in infectious mononucleosis is usually diffusely macular. MAIN OBSERVATIONS A 15-year-old boy presented to us with high grade fever, sore throat, malaise, body aches, and polyarthralgia. He developed annular, erythematous, and non-scaly eruptions on chest and right arm. Blanching erythema was noted on his trunk. He had bilateral tender cervical lymph nodes, severe pharyngeal congestion, petechiae on soft palate, uvular edema, infraorbital edema, and marginal tender hepatomegaly. Investigations revealed lymphocytosis and activated atypical lymphocytes in the peripheral smear, and positive monospot test. The boy subsequently recovered in one week with total disappearance of his rash. Epstein-Barr virus-related infectious mononucleosis was considered the most likely diagnosis for our patient. CONCLUSIONS To our knowledge, this atypical case is the third reported case of annular lesions in infectious mononucleosis. Dermatologists and other clinicians should be alerted to this special presentation of primary EBV infection.