Indian Journal of Dermatology Venereology and Leprology

BACKGROUND: Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis are severe cutaneous reactions caused by certain drugs, including antiepileptic carbamazepine. A strong association has been reported between human leucocyte antigen (HLA)-B*1502 and carbamazepine-induced SJS in Han Chinese patients. European studies suggested that HLA-B*1502 is not a universal marker but is ethnicity-specific for Asians. AIM: To study the association between HLA-B*1502 and carbamazepine-induced SJS in Indian patients. METHODS: Eight individuals who fulfilled the diagnostic criteria of SJS induced by carbamazepine were identified and HLA-B molecular typing was performed. HLA-B genotyping was carried out by polymerase chain reaction using sequence-specific primers. RESULTS: Out of eight patients studied for genotype, six patients were found to have the HLA-B*1502 allele. CONCLUSION: This study suggests an association between HLA-B*1502 and carbamazepine-induced SJS in Indian patients.

The increase in air pollution over the years has had major effects on the human skin. Various air pollutants such as ultraviolet radiation, polycyclic aromatic hydrocarbons, volatile organic compounds, oxides, particulate matter, ozone and cigarette smoke affect the skin as it is the outermost barrier. Air pollutants damage the skin by inducing oxidative stress. Although human skin acts as a biological shield against pro-oxidative chemicals and physical air pollutants, prolonged or repetitive exposure to high levels of these pollutants may have profound negative effects on the skin. Exposure to ultraviolet radiation has been associated with extrinsic skin aging and skin cancers. Cigarette smoke contributes to premature aging and an increase in the incidence of psoriasis, acne and skin cancers. It is also implicated in allergic skin conditions such as atopic dermatitis and eczema. Polyaromatic hydrocarbons are associated with extrinsic skin aging, pigmentation, cancers and acneiform eruptions. Volatile organic compounds have been associated with atopic dermatitis. Given the increasing levels of air pollution and its detrimental effects on the skin, it is advisable to use strategies to decrease air pollution.

Individual methodsAlthough acne vulgaris has plagued humankind since antiquity, the need for grading acne vulgaris was felt when the therapies available for treating acne increased in the 1950s.Probably, the first person to use a scoring system for acne vulgaris was Carmen How to cite this article: Adityan B, Kumari R, Thappa DM.Scoring systems in acne vulgaris.

Vitiligo, an autoimmune disorder characterized by localized and/or generalized depigmentation of the skin and/or mucous membranes, is a well-recognized entity. The imperatives of its epidemiology both in rural India and in global reckoning have been highlighted frequently. Its morphology is striking and is characterized by asymptomatic ivory/chalky white macule(s) that may be frequently surrounded by a prominent pigmented border, the 'trichrome vitiligo'. However vitiligo may have morphological variations in the form of: trichrome, quadri-chrome, penta-chrome, blue and inflammatory vitiligo. Its current topographical classification into segmental, zosteriform and nonsegmental, areata, vulgaris, acrofacialis and mucosal represent its well acclaimed presentations. Its adult and childhood onset is well appreciated as also its presentation in males and females. Occasionally, it may be possible to identify triggering factors. Vitiligo may be associated with cutaneous, ocular and systemic disorders, the details of which are discussed in this article.

Herpes zoster is a major health burden that can affect individuals of any age. It is seen more commonly among individuals aged ≥50 years, those with immunocompromised status, and those on immunosuppressant drugs. It is caused by a reactivation of varicella zoster virus infection. Cell-mediated immunity plays a role in this reactivation. Fever, pain, and itch are common symptoms before the onset of rash. Post-herpetic neuralgia is the most common complication associated with herpes zoster. Risk factors and complications associated with herpes zoster depend on the age, immune status, and the time of initializing treatment. Routine vaccination for individuals over 60 years has shown considerable effect in terms of reducing the incidence of herpes zoster and post-herpetic neuralgia. Treatment with antiviral drugs and analgesics within 72 hours of rash onset has been shown to reduce severity and complications associated with herpes zoster and post-herpetic neuralgia. This study mainly focuses on herpes zoster using articles and reviews from PubMed, Embase, Cochrane library, and a manual search from Google Scholar. We cover the incidence of herpes zoster, gender distribution, seasonal and regional distribution of herpes zoster, incidence of herpes zoster among immunocompromised individuals, incidence of post-herpetic neuralgia following a zoster infection, complications, management, and prevention of herpes zoster and post-herpetic neuralgia.

Androgenetic alopecia (AGA) is one of the commonest reasons for dermatological consultation. Over the last few years our understanding of the pathophysiology of AGA has improved and this has paved way for better diagnostic and therapeutic options. Recent research has dwelled on the role of stem cells in the pathophysiology of AGA and has also identified newer genetic basis for the condition. Dermoscopy/trichoscopy has emerged as a useful diagnostic tool for AGA. While the major treatment options continue to be topical minoxidil, systemic Finasteride and hair transplantations, newer modalities are under investigation. Specific diagnostic and treatment recommendations have also been developed on evidence based principles. This article reviews the recent concepts in relation to AGA. With regards to the pathophysiology we have tried to stress on recent knowledge of the molecular and genetic basis of AGA. We have emphasized on an evidence based approach for treatment and diagnosis.

BACKGROUND: Chronic renal failure (CRF) presents with an array of cutaneous manifestations. Newer changes are being described since the advent of hemodialysis, which prolongs the life expectancy, giving time for these changes to manifest. AIM: The aim of this study was to evaluate the prevalence of dermatologic problems among patients with chronic renal failure (CRF) undergoing hemodialysis. METHODS: One hundred patients with CRF on hemodialysis were examined for cutaneous changes. RESULTS: Eighty-two per cent patients complained of some skin problem. However, on examination, all patients had at least one skin lesion attributable to CRF. The most prevalent finding was xerosis (79%), followed by pallor (60%), pruritus (53%) and cutaneous pigmentation (43%). Other cutaneous manifestations included Kyrle's disease (21%); fungal (30%), bacterial (13%) and viral (12%) infections; uremic frost (3%); purpura (9%); gynecomastia (1%); and dermatitis (2%). The nail changes included half and half nail (21%), koilonychia (18%), onychomycosis (19%), subungual hyperkeratosis (12%), onycholysis (10%), splinter hemorrhages (5%), Mees' lines (7%), Muehrcke's lines (5%) and Beau's lines (2%). Hair changes included sparse body hair (30%), sparse scalp hair (11%) and brittle and lusterless hair (16%). Oral changes included macroglossia with teeth markings (35%), xerostomia (31%), ulcerative stomatitis (29%), angular cheilitis (12%) and uremic breath (8%). Some rare manifestations of CRF like uremic frost, gynecomastia and pseudo-Kaposi's sarcoma were also observed. CONCLUSIONS: CRF is associated with a complex array of cutaneous manifestations caused either by the disease or by treatment. The commonest are xerosis and pruritus and the early recognition of cutaneous signs can relieve suffering and decrease morbidity.

Dermatophytosis has attained unprecedented dimensions in recent years in India. Its clinical presentation is now multifarious, often with atypical morphology, severe forms and unusually extensive disease in all age groups. We hesitate to call it an epidemic owing to the lack of population-based prevalence surveys. In this part of the review, we discuss the epidemiology and clinical features of this contemporary problem. While the epidemiology is marked by a stark increase in the number of chronic, relapsing and recurrent cases, the clinical distribution is marked by a disproportionate rise in the number of cases with tinea corporis and cruris, cases presenting with the involvement of extensive areas, and tinea faciei.

Background Non tuberculous mycobacterial (NTM) infections are a heterogenous group of infections caused by more than 200 species of mycobacteria other than M. tuberculosis complex and M. leprae . The existing guidelines for treatment of NTM infections focus primarily on pulmonary infection. This consensus statement has been formulated for the diagnosis and management of cutaneous NTM infections (excluding M. marinum and M. ulcerans ). Objectives The aim was to develop consensus guidelines for diagnosis and management of cutaneous NTM infections in situations where the organism is identified with known drug susceptibility pattern, and when treatment has to be given empirically. Methods The modified DELPHI method was used for developing the guidelines. Agreement by 3 75% experts was considered as consensus. The panel consisted of nine experts including dermatologists, internists and microbiologists. Initially, 50 statements based on Likert scale were drafted and internally and externally validated. Three rounds were conducted, first two were sent by mail and the third was a live discussion on an online platform. Results Consensus was met on 33 statements which have been discussed in this article. The statement focusses on four key areas: clinical features, diagnostic criteria, investigations and specific and empirical treatment plans. Clinical diagnostic criteria have been agreed upon. Limitations The statement is based on collective experience of experts rather than real-time data. Hence, it should be interpreted as a guideline. Conclusion The consensus statement provides a guideline for dermatologists to identify and diagnose NTM infections. It also provides a step-by-step approach to treating NTM infection when identification of the organism becomes difficult, due to the nature of the disease or due to lack of facilities.

Background Biologics for psoriasis are typically administered after failure of conventional therapies, with affordability being an important factor in treatment decisions. Since tuberculosis (TB) is endemic in India, IL-17 monocloncal antibodies (mAbs) are often preferred due to their favourable safety profile compared to tumour necrosis factor (TNF)-α inhibitors. However, treatment failures with these agents do occur, raising concerns about their use across all patients with moderate-to-severe psoriasis. Objective Our objective was to analyse the secondary failures to secukinumab in moderate to severe psoriasis patients. The secondary objective was to analyse the cost and efficacy of other biologics after secondary failure to secukinumab. Methods All patients with psoriasis who had failed conventional therapy were administered secukinumab. After the induction phase (defined as treatment till 16 weeks), secukinumab was continued if psoriasis area severity index (PASI) 75 was achieved. Secondary failure was defined as the loss of response (PASI > 50% of the initial value) in a patient who had previously achieved PASI 50 response at week 16. Intra- or inter-class switching of biologics was attempted in these patients and the cost of therapy was calculated at the end of 16 weeks. Results Out of 42 patients who were administered secukinumab, 14 (33%) experienced secondary failure at a mean duration of 7.5 months. All these patients had received multiple conventional oral agents and 9/14 (64%) had received prior TNF-ɑ inhibitors. While secukinumab was up dosed (repeat loading dose given) in 3 patients, 6 were administered TNF-ɑ biologics and 5 were administered ixekizumab. All the patients who were switched to other biologics achieved improvement in PASI (38.7 at secondary failure - reduced to 26.7, p<0.001) with a significantly lowered PASI in the etanercept and ixekizumab group as compared to the secukinumab loading dose group ( p -value 0.003) at the end of the induction phase. Cost comparison revealed that TNF-ɑ biologics were economical alternatives in cases of secondary secukinumab failure, namely etanercept followed by adalimumab and ixekizumab. Limitations Small cohort and a retrospective single-centre design. Conclusion Our data suggests that in case of secondary secukinumab failure, TNFα biologics are a cost-effective option while updosing secukinumab is not consistently effective. However, more data with evaluation of long-term response and value based pricing is needed to guide public funded health care systems.

People with skin of colour represent a vastly heterogenous group of individuals with different ancestral backgrounds, skin colours and skin reactivity. While the Fitzpatrick skin type scale was designed to describe the reactivity of skin to ultraviolet light, it has been applied beyond its original intent for the purpose of skin colour classification. In light of the shortcomings of the Fitzpatrick skin type in classifying skin of colour, several other classification systems have emerged. This review article presents the evolution of classification systems for skin of colour. Favourable features of classification schemes include wide colour spectrums as well as aspects beyond skin colour, such as UV (ultraviolet) reactivity, ethnicity, pigmentation tendencies, wrinkling, naevi location or a combination of these factors. Drawbacks of some classification scales include over-emphasis of ancestry and complicated implementation. Scales vary widely in their potential applications. As such, application of classification schemes appears most appropriate in a situation-specific manner with no universally applicable, gold standard scale for skin of colour. The skin of colour population is growing worldwide, which will dramatically shift future patient populations, illustrating the need to improve characterisation of skin of colour in dermatologic practice. While remarkably complex and heterogeneous, the need for a widely applicable, meaningful and consistent method of skin of colour classification continues to grow, which is not met by our existing classification systems.

Acute graft rejection following bilateral cadaveric hand transplantIn the article "Acute graft rejection following bilateral cadaveric hand transplant," published in the Indian Journal of Dermatology, Venereology and Leprology, 1 there were errors/ inadequacies in the presentation of some of the sections.The author has provided additional corrections to update the same.These are as follows:How to cite this article:

Beyond cutaneous xanthogranulomas: Recognising the existence of mixed histiocytosisIn the article "Beyond cutaneous xanthogranulomas: Recognising the existence of mixed histiocytosis," published in the Indian Journal of Dermatology, Venereology and Leprology, 1 there were errors/inadequacies in the presentation and legends of Figures 2a, 2b, 3a, and 3b.