Dermatology, Venereology, Leprology

Research ethics in the modern era Sayanta Thakur, Sandeep Lahiry Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):351-354

A double-blind, randomized controlled trial to compare the effectiveness and safety of purified protein derivative of tuberculin antigen with Mycobacterium w vaccine in the treatment of multiple viral warts Somodyuti Chandra, Amrita Sil, Adrija Datta, Santasmita Pal, Nilay Kanti Das Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):355-366 Background: Present day therapeutic modalities for viral warts are mostly ablative in nature, limited by high recurrence rates and are unsuitable for numerous lesions. Immunotherapy has the potential to overcome these limitations. Aims: This study aimed at comparing efficacy and safety of and quality of life changes with intradermal purified protein derivative (PPD) of tuberculin antigen and Mycobacterium w (Mw) vaccine in immunotherapy of warts. Methods: Patients with multiple (≥5) warts were randomized (1:1) into two groups (PPDand, Mw vaccine groups). Fortnightly, 0.1 ml of either medicine was injected intradermally over the deltoidregion till complete resolution or a maximum of six doses. Patients were followed-up for another 3 months for recurrence. Results: Sixty-four participants received either PPD or Mw vaccine. The number of warts were comparable at baseline (P = 0.089, Mann–Whitney test), and reduced significantly with treatment in both groups (P < 0.001, Friedman's ANOVA), as seen from the fourth follow-up onwards with Mw and fifth follow-up onwards with PPD (P < 0.05, Post hoc Dunn's test). Intergroup comparison showed significantly more (P < 0.05, Mann–Whitney test) reduction with Mw than PPD at the sixth and seventh follow-up. The size of warts also reduced significantly (P < 0.001) in both groups from the third follow-up onwards. Complete remission was more (P = 0.539, Fischer's exact test) in the Mw group (68.8%) than the PPD group (50%); and was significantly higher (P = 0.049, Mann–Whitney test) in patients having shorter duration of warts. Adverse events were significantly more (P < 0.001) with Mw including ulceration (50%), discharge (15.6%), pain-swelling-induration and scar at the injection site (97% each), whereas some of those receiving PPD noted erythema and scaling at the injection site (18.8%), and post-inflammatory hyperpigmentation (12.5%). No recurrence was seen till the end of the study. Limitation: Unicentric trial. Conclusion: Intradermal injection of Mw vaccine was more effective but had a higher incidence of adverse effects compared to PPD of tuberculin antigen in patients with warts.

Histopathological comparison of lesional and perilesional skin in melasma: A cross-sectional analysis Manjyot Gautam, Sharmila Patil, Nitin Nadkarni, Manjit Sandhu, Kiran Godse, Maninder Setia Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):367-373 Background: Melasma is a common acquired hyperpigmentary disorder of the sun exposed skin, especially the face. The pathogenesis is unclear but interplay between genetic factors, hormones and ultraviolet radiation is important. We have evaluated the histological characteristics of melasma and compared the findings with adjacent normal skin. Methods: Skin biopsies were taken from both melasma and the surrounding perilesional normal skin in 50 Indian women. The sections were stained with hematoxylin and eosin, Fontana–Masson and Verhoeff–Van Gieson stains. Results: Biopsy from melasma showed significant epidermal atrophy, basal cell hyperpigmentation and solar elastosis when compared with the perilesional skin. We found that the proportion of pendulous melanocytes was significantly higher in the lesional biopsy compared with the perilesional biopsy (76% vs 42%, P < 0.001). Similarly, pigmentary incontinence and features of solar elastosis were significantly higher in the lesional skin compared with the perilesional skin. Conclusion: The characteristic histopathological features such as epidermal atrophy, basal cell hyperpigmentation and solar elastosis suggest the role of chronic sun exposure in the pathogenesis of melasma. Presence of pendulous melanocytes is a characteristic feature of melasma. The presence of pendulous melanocytes may have prognostic implications in melasma.

New insights into leukotrichia in nonsegmental vitiligo: A cross-sectional study Rania M Mogawer, Maha Fathy Elmasry, Wedad Z Mostafa Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):374-379 Background: Leukotrichia has been considered a predictor of poor outcome in vitiligo. However, studies considering the different clinical aspects of leukotrichia in vitiligo patients are few. Aim: Our aim was to conduct a detailed clinical study to provide insights into the relevance and associations of leukotrichia in non-segmental vitiligo. Methods: In this cross-sectional study, vitiligo patients attending the dermatology outpatient clinic and phototherapy unit at Cairo University Hospital over a period of 6 months (April–September 2016) were included. Family history, clinical details, the Vitiligo Global Issues Consensus Conference classification, the Dermatology Life Quality Index, Vitiligo Area and Severity Index, Vitiligo Extent Score, Vitiligo Disease Activity Score and Vellus Score were determined and these measurements were correlated to leukotrichia. Results: Out of the 101 patients studied, leukotrichia was found in 47 (46.5%) patients, with vellus hair involved in 37 (78.7%), terminal hairs in 30 (63.8%) and both in 20 (42.5%) patients. Vellus hair involvement was significantly higher in generalized bilaterally symmetrical vitiligo than in acrofacial or unclassified vitiligo. The incidence of scalp leukotrichia also was higher in generalized symmetrical vitiligo than in acrofacial vitiligo. The Vellus Score showed significant associations with Vitiligo Area and Severity Index, Vitiligo Extent Score and the Dermatology Life Quality Index. Limitations: This was a short-term study with a small sample size. Prognostic and therapeutic correlations were not studied; prospective longitudinal studies are needed for further evaluation. Conclusion: Leukotrichia was found in almost half of the studied sample and its frequency varied among the different types of vitiligo.

Do primary care physicians require training in core clinical dermatology? A cross sectional needs assessment study from Western India Sejal H Thakkar, Paragkumar D Chavda, Kedar G Mehta Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):380-387 Background: Primary care physicians play a crucial role in managing patients with common skin disorders who form around one-third of outpatient attendees. Aim: This study aimed to assess the need for dermatology training among primary care physicians by assessing their knowledge, self-perception of ability to diagnose and manage skin disorders, and their difficulties in managing these patients. Methods: A descriptive, cross-sectional, needs assessment study was done among primary care physicians (n = 61) of rural (n = 34) and urban (n = 27) areas of Vadodara district. A pre-validated semi-structured questionnaire (for self-rating of the ability to diagnose/manage skin disorders and difficulties faced in managing patients) was used along with a photo-quiz (for knowledge assessment) while approaching primary care physicians during their monthly review meeting with prior permission. Data were analyzed by Epi InfoTM software and manual content analysis. Results: The mean score on the photo-quiz was 4.1/10. Forty-three (70.5%) participants rated their ability to diagnose/manage skin disorders as 'average' on a five-point Likert scale. Various difficulties (n = 89) narrated by participants were related to their knowledge/skill, disease factors, patients and administrative aspects. Three-fourths of the participants managed difficulties by referring patients to dermatologists. One-third suggested conducting training in common skin disorders. Limitations: The study population included primary care physicians from the government healthcare setup only. Knowledge assessment was done using a short ten-item photo-quiz instead of actual patients. Conclusions: Primary care physicians had poor knowledge of skin disorders, and a majority overrated their own ability for clinical management of these disorders. Most common difficulties faced were related to clinical management. There is a need for training on common skin disorders.

In vitro susceptibility of dermatophytes to oral antifungal drugs and amphotericin B in Uttar Pradesh, India Satyendra Kumar Singh, Dheeraj Kumar Patwa, Ragini Tilak, Arghya Das, Tej Bali Singh Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):388-392 Background: Dermatophytosis is a major public health problem in our country. Although resistance to conventional oral and topical antifungal agents is being increasingly encountered, the sensitivity pattern of dermatophytes has not been systematically analysed. Aims: We aimed to determine the sensitivity pattern of dermatophyte isolates to amphotericin B and six oral antifungal drugs. Materials and Methods: Patients with dermatophytosis attending the outpatient department of dermatology were enrolled in the study. Samples were collected for mycological examination and in vitro antifungal sensitivity testing was done by broth microdilution as per the Clinical and Laboratory Standard Institute M38-A standards. Results: A total of 804 patients were enrolled. Specimens from 185 patients (23%) were both KOH and culture positive, and 44 of these isolates (41 Trichophyton mentagrophytes and 3 Trichophyton rubrum) were subjected to sensitivity testing. Minimum inhibitory concentrations (MIC) of itraconazole, ketoconazole, voriconazole and amphotericin B were comparable. The median MIC to fluconazole was higher than the other tested drugs. Dermatophytes were most susceptible to ketoconazole and voriconazole, followed by itraconazole, amphotericin B, fluconazole and griseofulvin. A high incidence of resistance was found to terbinafine and the difference was statistically significant in comparison to fluconazole, itraconazole, voriconazole, ketoconazole (P = 0.001) and griseofulvin (P = 0.003). The strains were more sensitive to amphotericin B as compared to griseofulvin (P = 0.02) and terbinafine (P < 0.001). Limitations: This was a hospital-based study and may not reflect the true pattern in the community. Only a few of the isolates were selected for study. The clinical response of patients, whose isolates were studied for in vitro sensitivity of the antifungals, was not studied. Conclusions: The sensitivity pattern of dermatophytes to various antifungals including amphotericin B, ketoconazole, voriconazole and itraconazole were determined. The studied isolates were least susceptible to terbinafine.

Multiple adenoid basal cell carcinoma: An uncommon presentation Ajit Agarwal, Anand Raja, Sivakumar Mahalingam, Kanchan Murhekar Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):393-396 Basal cell carcinoma (BCC) is the most common malignant skin tumor which occurs more frequently over the sun exposed parts of body. Its adenoid variant is a rare histological subtype. We report a case of multiple adenoid basal cell carcinomas at unusual sites in a middle-aged male patient.

Evaluation of efficacy and safety of intralesional bleomycin in the treatment of common warts: Results of a pilot study Karan Inder Singh Mehta, Vikram K Mahajan, Pushpinder Singh Chauhan, Shailja Chauhan, Vikas Sharma, Ritu Rawat Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):397-404 Background: This study evaluated the efficacy and safety of intralesional bleomycin in the treatment of common warts in 50 (32 men, 18 women) patients aged between 14 and 80 (mean ± SD, 28.5 ± 13.27) years. Methods: The warts were present over dorsal hands, feet, palms, soles and periungual skin for 1 month to 10 years. They were infiltrated with bleomycin (1 mg/ml) till blanching. The total cumulative dose did not exceed 2 mg in one session. The treatment was repeated after paring of eschar at 2 weeks in case there was no or partial response. The patients were reviewed at 4, 12 and 24 weeks for cure, adverse effects or recurrences and outcome satisfaction levels. Results: Complete cure without recurrence occurred in 40 (80%) patients and partial response occurred in 7 (14%) patients at the end of the 24-week study period. Three patients did not complete follow-up. No major systemic or local adverse effects other than injection site pain for 2–3 days were noted. All cured patients were very satisfied (Likert scale 5). Conclusion: Intralesional bleomycin appears to be an effective and safe treatment for common warts including palmoplantar and periungual warts. It carries the advantage of low dose, no significant adverse effects and high patient satisfaction. Small number of patients, lack of a control group, comparing different bleomycin concentrations and a short follow-up are a few limitations of this study. Better designed studies are warranted for this useful treatment modality.

Erythema ab igne Jaime Company-Quiroga, Sergio Alique-García, Alberto Romero-Maté Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):405-406

Persistent perioral papules in a young man Piyush Kumar, Anupam Das, Rizwana Barkat Indian Journal of Dermatology, Venereology, and Leprology 2019 85(4):407-409

Alexandros Sfakianakis
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