Vikram K. Mahajan

Onychomycosis: Clinico-mycologic study of 130 patients from Himachal Pradesh, India

BACKGROUND Onychomycosis is a common nail infection caused by dermatophytes, yeast or other nondermatophyte molds and has diverse clinical presentations. Although common in this part of the country, no significant clinico-mycologic data is available. OBJECTIVES This study was carried out to document the clinico-mycologic pattern of onychomycosis in Himachal Pradesh (India). METHODS All consecutive patients of onychomycosis diagnosed clinically during March 2005 to February 2006 were studied for clinical forms, number of nails involved and severity of infection. The clippings from the most severely affected nails were subjected to potassium hydroxide (KOH) mounts for direct microscopy and fungal culture on Sabourauds dextrose agar. RESULTS These 130 patients (M:F 98:32) were between 8-76 years of age (mean 41.35 +/- 14.98 years). The prevalence of onychomycosis was higher among farmers and office workers (20% each). Finger or toe nails were exclusively involved in 56.9 and 32.3% patients respectively while these were involved concurrently in the rest of the 10.8% patients. Distal and lateral subungual onychomycosis seen in 73.1% of the specimens was the most common clinical type. KOH- and culture-positivity were recorded in 59.2 and 37.6% cases respectively. Dermatophytes and yeast (Candida albicans) were isolated in 40.8% each of the cultured nail specimens while nondermatophytic molds (NDM) were cultured in 18.6% of the samples. Various dermatophytes cultured were Trichophyton rubrum (32.6%), T. mentagrophytes (6.1%) and T. verrucosum (2.1%) respectively. Aspergillus spp. (6.1%) was the most commonly isolated NDM while other detected molds were Acremonium spp, Fusarium spp,, Scopulariopsis spp, Curvularia spp. and Penicillium marneffei. Peripheral vascular disorders (7.69%), occupational trauma (13.8%), close association with animals (60.78%) and a family history of onychomycosis (26.15%) were a few of the predisposing factors identified. CONCLUSION Onychomycosis is not uncommon in this part of the country and has similar clinico-mycologic profiles in the different cases detected.

Chromoblastomycosis in India

Background Four patients with chromoblastomycosis are presented. An additional 30 infected Indian patients are reviewed.

Twelve-year clinico-therapeutic experience in pemphigus: a retrospective study of 54 cases.

Background  Pemphigus, a common immunobullous disease of skin and mucous membranes affecting both sexes of all ages, was almost fatal before the advent of corticosteroids. Better strategies to avoid their side‐effects and recent introduction of adjuvant therapy has further improved its prognosis. As the treatment remains need‐based and patient‐specific, different regimens and strategies have evolved, each with its own merits and demerits.

Cutaneous sporotrichosis in Himachal Pradesh, India

During the period 1990–2002 in Himachal Pradesh, India, 103 new patients with cutaneous sporotrichosis were detected. Lymphocutaneous and fixed cutaneous varieties were the most common and seen in 49% and 43% respectively. Chronic non‐specific inflammation without granuloma formation was seen in 46% skin biopsy specimens, 29% showed acute or chronic inflammation and tuberculoid granuloma formation was seen in 25%. In 32% of cases Sporothrix schenckii growth was seen on Sabouraud glucose agar. A saturated solution of potassium iodide was used as first‐line treatment and in 93% patients healing of lesions occurred in 4–32 weeks (average 8.7 weeks) without significant side‐effects. Itraconazole, used in 12 patients, was highly effective in recommended doses. Rapid healing was seen with higher than previously used doses of fluconazole in one patient who also had unusual exacerbation of lesional inflammation with saturated solution of potassium iodide.

Zinc Therapy in Dermatology: A Review

Zinc, both in elemental or in its salt forms, has been used as a therapeutic modality for centuries. Topical preparations like zinc oxide, calamine, or zinc pyrithione have been in use as photoprotecting, soothing agents or as active ingredient of antidandruff shampoos. Its use has expanded manifold over the years for a number of dermatological conditions including infections (leishmaniasis, warts), inflammatory dermatoses (acne vulgaris, rosacea), pigmentary disorders (melasma), and neoplasias (basal cell carcinoma). Although the role of oral zinc is well-established in human zinc deficiency syndromes including acrodermatitis enteropathica, it is only in recent years that importance of zinc as a micronutrient essential for infant growth and development has been recognized. The paper reviews various dermatological uses of zinc.

Sporotrichosis: An Overview and Therapeutic Options

Sporotrichosis is a chronic granulomatous mycotic infection caused by Sporothrix schenckii, a common saprophyte of soil, decaying wood, hay, and sphagnum moss, that is endemic in tropical/subtropical areas. The recent phylogenetic studies have delineated the geographic distribution of multiple distinct Sporothrix species causing sporotrichosis. It characteristically involves the skin and subcutaneous tissue following traumatic inoculation of the pathogen. After a variable incubation period, progressively enlarging papulo-nodule at the inoculation site develops that may ulcerate (fixed cutaneous sporotrichosis) or multiple nodules appear proximally along lymphatics (lymphocutaneous sporotrichosis). Osteoarticular sporotrichosis or primary pulmonary sporotrichosis are rare and occur from direct inoculation or inhalation of conidia, respectively. Disseminated cutaneous sporotrichosis or involvement of multiple visceral organs, particularly the central nervous system, occurs most commonly in persons with immunosuppression. Saturated solution of potassium iodide remains a first line treatment choice for uncomplicated cutaneous sporotrichosis in resource poor countries but itraconazole is currently used/recommended for the treatment of all forms of sporotrichosis. Terbinafine has been observed to be effective in the treatment of cutaneous sporotrichosis. Amphotericin B is used initially for the treatment of severe, systemic disease, during pregnancy and in immunosuppressed patients until recovery, then followed by itraconazole for the rest of the therapy.

Thalidomide: An experience in therapeutic outcome and adverse reactions

Background: The US FDA‐approved thalidomide for the treatment of chronic recurrent/severe erythema nodosum leprosum. Thalidomide is also useful in many other inflammatory dermatological conditions where patients have exhausted other treatment options. Methods: The beneficial and adverse clinical effects of thalidomide were studied in 25 patients suffering from different inflammatory dermatological conditions that were poorly controlled with conventional therapies. Results: Thalidomide was found to be effective in various inflammatory dermatological diseases other than chronic recurrent erythema nodosum leprosum such as Behçets disease, disseminated and hypertrophic discoid lupus erythematosus, erosive lichen planus, discoid lupus erythematosus‐lichen planus overlap, recurrent aphthous stomatitis and prurigo nodularis. Deep vein thrombosis due to thalidomide occurred in 20% of these patients and appears to be a significant side effect. Conclusion: Thalidomide appears promising in a number of inflammatory dermatological conditions and will probably find new usages in future. The treating physicians need to be wary of the thrombo‐embolic complications due to thalidomide especially when glucocorticoids or other chemotherapeutic agents such as doxorubicin, gemcitabine, 5‐fluorouracil or dexamethasone‐cyclophosphamide pulse therapy are being used concomitantly, and in patients of metastatic renal carcinoma, myelodysplastic syndrome or multiple myeloma receiving thalidomide/chemotherapy. Antiphospholipid or anticardiolipin antibodies appear to be other possible risk factors for this complication.

Isolation of Sporothrix schenckii from the environmental sources of cutaneous sporotrichosis patients in Himachal Pradesh, India : results of a pilot study

Himachal Pradesh, India is a known endemic area for cutaneous sporotrichosis. No attempt has been made to isolate Sporothrix schenckii, the causative fungus, from environmental sources in this region or in India as such. This prospective study was carried out to isolate Sporothrix schenckii from different environmental samples collected from the vicinity of cutaneous sporotrichosis patients. All patients of cutaneous sporotrichosis diagnosed during March 2005–February 2006 were studied. Twenty‐one biopsy specimens and 62 environmental samples of soil, various thorns, corn‐stalk, grass‐blades and sphagnum moss were subjected to mycologic culture on Sabouraud’s glucose agar. Sporothrix schenckii was identified by colony characteristics, lacto‐phenol cotton blue mounts and demonstration of temperature dimorphism. These patients (F : M 15 : 6) were between 12 and 72 years of age and had cutaneous lesions for 45 days to 4 years. Lymphocutaneous and fixed cutaneous sporotrichosis was seen in 14 (66.6%) and 7 (33.3%) patients respectively. Extremities were involved in 16 (76.2%); and 5 (23.8%) patients had facial lesions. Ten (47.4%) biopsy specimens and six environmental (three soil, three corn‐stalk) samples were culture‐positive, which showed morphological characteristics suggesting Sporothrix schenckii. No variation in colony characteristics and mycelial morphology was observed in growth isolates from clinical or environmental samples. Temperature dimorphism was observed in all the 10 isolates obtained from the clinical specimens and in two isolates cultured from corn‐stalk. Corn‐stalks are evidently important sources of Sporothrix schenckii infection although subsequent contamination of wounds appears more important for development of clinical disease. Culture of Sporothrix schenckii from environmental sources may not be always possible to correlate with profile of injuries.

Methotrexate versus hydroxycarbamide (hydroxyurea) as a weekly dose to treat moderate‐to‐severe chronic plaque psoriasis: A comparative study

Background: Literature is replete with reports on the therapeutic efficacy and toxicity of methotrexate or hydroxycarbamide for treating chronic plaque psoriasis but no comparative study on their efficacy/safety has been carried out. While methotrexate has long been used in weekly doses in the treatment of psoriasis, the efficacy of hydroxycarbamide as a weekly therapy remains universally unexplored. Methods: Two groups of 15 patients each having moderate‐to‐severe chronic plaque psoriasis were given weekly doses of methotrexate (15–20 mg/week) or hydroxycarbamide (3–4.5 g/week). The clinical response was assessed by the percentage reduction in the baseline PASI scores for the next 12 weeks. Results: At the end of 12 weeks, the mean percentage reduction in the PASI score was 77.28±18.80 in the methotrexate group and 48.47±26.53 in the hydroxycarbamide group. Ten (66.66%) patients in the methotrexate group achieved >75% reduction in the PASI score, while in the hydroxycarbamide group only two (13.33%) patients showed similar results, signifying that methotrexate leads to a faster clearance of the disease. The methotrexate‐related side effects, however, were also higher. Conclusions: Weekly doses of hydroxycarbamide can be used as an alternative to methotrexate in patients who either experience intolerable methotrexate side effects or have achieved its recommended cumulative dose.

Trichotillomania and trichophagia leading to trichobezoar.

A 14‐year‐old female presented with the complaints of loss of hair, scalp pruritus, and pain in the abdomen. On careful work‐up, she was found to have trichotillomania as well as trichophagia. Investigations also revealed a trichobezoar which completely filled the stomach. Hemogram showed moderate hypochromic anemia. Her detailed psychiatric profile showed a few additional features like obsessive hand washing, knuckle cracking, nose picking and body rocking. Her trichobezoar was removed surgically, and she had an uneventful post‐operative recovery. She is being maintained on fluoxetine and is doing well. The role of a multi‐disciplinary approach to trichotillomania patients is highlighted.