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   Table of Contents - Current issue
July-December 2021
Volume 7 | Issue 2
Page Nos. 51-112

Online since Tuesday, December 14, 2021

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IL-23 blockers in dermatology p. 51
Shrichand G Parasramani, Manasi Shirolikar
Interleukin-23 (IL-23) is the key regulatory cytokine in psoriasis, which stimulates differentiation, proliferation, and survival of T-helper 17 (Th17) cells. Specific targeting of IL-23–IL-17 inflammatory pathway has become an effective therapeutic approach to treat psoriasis. Clinical studies have shown that antibodies directed against the p19 subunit of IL-23 show equal or superior response as compared to when both IL-12 and IL-23 are inhibited. Side effects of IL-12 inhibition are avoided. Tildrakizumab, guselkumab, and risankizumab are antibodies that target the p19 subunit of IL-23. These newer IL-23 blockers give high PASI response and are easy to administer once in 8–12 weeks. A comparison of these three drugs from different trials is carried out in this review with the help of bar charts. There are no head-to-head comparative trials of these monoclonal antibodies.
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Effective treatment option for lichen planus: Steroids or low molecular weight heparins? p. 60
Neelima Parlapalli, Tina Priscilla
Background: Data on safety and efficacy of low molecular weight heparin (LMWH) in lichen planus (LP) and comparison with oral corticosteroids (OCs) in Indian patients is limited. Aims: The aim of this article is to compare the clinical efficacy of LMWH and systemic corticosteroids in LP. Materials and Methods: This study was a single-center prospective comparative study. The patients received either LMWH subcutaneously (3 mg weekly for 6 weeks) or OC (20 mg/day for 6 weeks, tapered gradually). Results: Fifty patients were enrolled in the study, and 35 (70.0%) were females. Mean age of the study population was 35.46 years with age ranging between 21 and 40 years. Itching (92.0%) was a common symptom; generalized cutaneous lesions (90.0%) and involvement of mucous membrane were seen in 40%. Classical LP was common (56.0%). Early results were seen with OC (week 4) compared to LMWH (week 5); higher cure rate was seen with OC (89.47% vs. 76.0%) at week 6. There was no significant statistical difference (P > 0.05) in the therapeutic response between the study groups. No new lesions were noted in 23 and 13 patients treated with OC and LMWH, respectively. Relapse rate (33.33%) was higher in patients treated with LMWH (P < 0.05). Treatment with low-dose LMWH was associated with no side effects, whereas gastric irritation (42.1%) was the most common side effect followed by facial puffiness (31.57%) and acneiform eruptions (26.31%) with OC. The cost of treatment was more for LMWH compared with OC. Conclusion: Both treatment modalities were comparable in efficacy and tolerated well. LMWH had no adverse effect but had a high relapse rate. Therapy with OC is cost-effective.
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Comparative clinical assessment of 5% minoxidil topical application with supplemental intradermal meso-solution administration for the management of androgenetic alopecia in men p. 67
Neha Gupta, Sarvraj Kohli
Objectives: Androgenetic alopecia (AGA) is characterized by progressive patterned hair loss from the scalp affecting both men and women. The aim of this study was to evaluate the influence of intradermal administration of meso-solution (MS) along with topical application of 5% minoxidil lotion on hair re-growth. Materials and Methods: Sixty healthy adult men (32.6 ± 4.3 years of age) with a history of hair loss completed the 12-month study. They were equally randomized into two groups. Subjects enrolled in Group A (n1 = 30) received once-daily topical application of 5% minoxidil lotion, whereas those in Group B (n2 = 30) received additional intradermal injection of MS (Stem C’rum HL, Caregen Co. Ltd, Anyang-si, Gyeonggi-do, South Korea) using a mesogun every 15 days for 3 months and then once every month for 9 months. Hair re-growth was evaluated using a 7-point rating scale. Results: Data collected were subjected to chi-square test. Results indicate that there is a statistically significant (P < 0.05) increase in hair re-growth in individuals in Group B at 6 months. This progressed to a highly significant (P < 0.001) increase at 9 and 12 months. Conclusion: Intradermal administration of MS using a mesogun along with minoxidil yielded a statistically significant increase in hair re-growth as compared to only minoxidil application.
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Morphometric analysis of itraconazole pellets of commonly available brands using dermoscopy p. 72
Gajanan A Pise, HT Komala, Shilpa V Dastikop, Naveen Manohar, LM Akshay, Vinitha Sanagoudar
Introduction: Itraconazole (ITZ) is commonly used to treat cutaneous and systemic mycoses. The bioavailability of ITZ capsules varies between individuals; therefore, the quality of ITZ pellets is a major determinant of their absorption and therapeutic efficacy. Morphometric analysis is a surrogate method of evaluating the absorption and efficacy of ITZ capsules, and the number and size of pellets in each capsule are the most important morphometric parameters. Aim: To analyze the morphometric characteristics of commonly available brands of ITZ. Materials and Methods: Commonly available formulations of ITZ in the market were analyzed using a hand-held dermoscope. Morphometric characteristics of 30 and 10 brands of 100-mg and 200-mg formulations were analyzed, respectively. A dermoscope was used to determine the size and the number of pellets per capsule. Furthermore, variations in the size of pellets across brands were compared to that in the global innovator brand. Statistical analysis used was SPSS v. 21 (IBM Inc., Armonk, NY). Results: The capsules included 126–1010 pellets of 788–2343 µm, and dummy pellets and loose powder were found in some brands. Five brands that cost <20 Indian rupees (INR) per capsule included good pellet count, small pellet size, and low size variation. Two other brands included these qualities but were priced at INR 20–30 per capsule. The size variation was the minimum, and no dummy particles or loose powder were observed with the innovator brand; however, it was the costliest. Conclusion: The morphometric characteristics of ITZ formulations varied significantly between brands, which may significantly affect their efficacy.
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Comparative study of PUVA and NB-UVB in the management of chronic plaque psoriasis p. 79
Angoori Gnaneshwar Rao, Kranthi Jagadevapuram
Background: There are independent studies on PUVA and NB-UVB therapy for the treatment of psoriasis, but studies comparing both PUVA and NB-UVB are scarce. Aim: The aim of this study was to compare the efficacy and safety of PUVA and NB-UVB therapy in chronic plaque psoriasis. Materials and Methods: Fifty patients of chronic plaque psoriasis of more than 20% of body surface area and of more than 2 years duration with Psoriasis Area Severity Index (PASI) score of more than 10, aged above 12 years, were subjects in the study. PASI score was recorded. Patients were randomly allocated to one of the two groups, each consisting of 25 patients and administered therapy as per protocol: Group A: PUVA—psoralens + UVA or Group B: NB-UVB phototherapy. Therapeutic response of patients was followed up every week and PASI score was calculated at 0, 2, 4, 6, 8, 10, and 12 weeks. Observations: Commonest age group afflicted in both the groups was 31–40 years. There was significant improvement (P-value <0.0001) from baseline to 12th week in patients subjected to PUVA as well as NB-UVB therapy. In the PUVA group, minimum and maximum duration of treatment for PASI 75 was 5 and 11 weeks, respectively, whereas in the NB-UVB group it was 6 and 12 weeks, respectively. In the PUVA group, minimum and maximum number of exposures for PASI 75 was 10 and 22, respectively, and in the NB-UVB group it was 18 and 36, respectively. Conclusion: PUVA and NB-UVB are both effective therapies. However, NB-UVB is considered as good, effective, and safer treatment for plaque psoriasis with no or minimal long-term carcinogenic risk, and it can be safely used in children, pregnant women, and in patients with hepatic and renal insufficiency. However, more number of exposures and less energy (joules) are required in NB-UVB to achieve therapeutic target. Limitations: The number of cases in the study is less.
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Lenalidomide in a case of thalidomide intolerant erythema nodosum leprosum p. 84
Shankar Lal Chahar, Sidharth Mani, Jandhyala Sridhar, Padmapriya Srinivasan
Lenalidomide is an immunomodulatory drug, which is considered to be a derivative of thalidomide. It has a more potent suppressive effect on tumor necrosis factor-α (TNF-α) production and has a more tolerable adverse effect profile as compared to its parent drug. It has been approved by FDA for use in multiple hematopoietic malignancies and myelodysplasia, but unlike thalidomide its use in erythema nodosum leprosum (ENL) has not been reported so far. Herein we report a case of 45-year-old man with Hansen’s disease (BL) on MDT for 4 months who presented with ENL and was managed with minimum dose of lenalidomide.
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Rituximab in childhood pemphius vulgaris: A case report p. 88
Vinay Kulkarni, Swaraj Potdar, Pallavi Shirol
Pemphigus vulgaris (PV) is an autoimmune bullous disease. It has a very low incidence in childhood with very few cases reported in literatures. A 6-year-old female child had non-healing oral erosions for a month and recent appearance of genital erosions. Differential diagnoses considered were oral candidiasis, herpetic stomatitis, and PV. On investigating further, KOH mount showed Candidial hyphae and spores. Serology for herpes viruses was negative. Tzanck smear showed acantholytic cells. Obtaining biopsy from oral mucosa was difficult; hence, indirect immunofluorescence was done which showed significant titers of anti-epidermal (pemphigus) antibodies. Anti-desmoglein 1 and 3 antibodies measured by ELISA were also positive. Final diagnosis was PV. The patient was started on oral prednisolone. However, when relapsed, considering the long-term adverse effects of systemic corticosteroids on growth of the child, two infusions of rituximab, 15 days apart, were administered after clearance from a pediatrician and appropriate laboratory work up. Outcome: There was complete remission after 1 month of rituximab. Prednisolone was tapered off quickly and withdrawn completely. There was a persistent decline in anti-desmoglein antibodies during follow-up. No severe adverse effects were documented. The child remained in remission up to 12 months of follow-up. Discussion: This is a very rare case of childhood PV. Rituximab appears to be an effective therapeutic option in children with pemphigus. Further studies will help in defining protocols for use of rituximab in children.
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Single dose etanercept monotherapy for treating Stevens–Johnson syndrome p. 91
Vikas Pathania, Rohit Kothari, Durga M Tripathy, Prashant Sengupta, Deepak Vashisht, Prerna Shankar
Stevens–Johnson syndrome (SJS) is a delayed type hypersensitivity reaction to drugs and less commonly infections. The entity represents one end of the spectrum of SJS-TEN (Toxic Epidermal Necrolysis) complex. Together, both conditions contribute to the majority of Severe Cutaneous Drug Reactions (SCARs) with high mortality and morbidity. Clinically, it presents with widespread painful erythematous macules, targetoid lesions, full-thickness or focal epidermal necrosis while mucosal involvement involves oral, genital, and ocular mucous membranes along with preceding prodromal flu like symptoms. While there is no consensus on the treatment of choice, systemic steroids, intravenous immunoglobulin and cyclosporin are most often employed for specific management of SJS-TEN. We report a case of SJS managed with a single dose of etanercept monotherapy.
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Amorolfine-induced allergic contact dermatitis p. 95
Kaustav Saha, Shatavisa Mukherjee
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Neutrophilic eccrine hidradenitis presenting in a case of acute undifferentiated leukemia before chemotherapy p. 97
Akash Agarwal, Priyanka Samal, Debahuti Mohapatra, Bikash Ranjan Kar
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Treatment of florid COVID-19-associated mucosal candidiasis and the diagnostic dilemma of suspected mucormycosis p. 99
Sharad D Mutalik, Vinay V Kulkarni, Yashashree Dhaval Rasal, Tejaswini Sopanrao Salunke
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Successful treatment of actinic reticuloid with nonsteroidal immunosuppressive drugs p. 101
Bhavna Haresh Chandwani, Snehal Balwant Lunge, Vidyadhar Rajaram Sardesai
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Linezolid-induced black hairy tongue p. 104
Arumugam Iswarya, Kaliaperumal Karthikeyan
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Drug-induced liver injury: What a dermatologist should know? p. 106
Anwita Sinha, Shekhar Neema, Manish Manrai, Biju Vasudevan, S Radhakrishnan
Dermatological practice involves the use of systemic drugs; some of them carrying boxed warnings of hepatotoxicity while others causing inadvertent or idiosyncratic liver damage. Drug-induced liver injury (DILI) is a common problem faced by dermatologists and refers to liver damage caused by medications, herbs, or other xenobiotics which can sometimes be fatal. Diagnosis of DILI remains challenging due to nonspecific clinical presentations compounded by a lack of knowledge in this area. With careful patient selection and systematic monitoring, liver injury should be rare in the dermatological setup. This review article is written with the aim of increasing awareness of DILI among dermatologists and thereby preventing liver injuries from common drugs.
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