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   Table of Contents - Current issue
January-June 2019
Volume 3 | Issue 1
Page Nos. 1-108

Online since Thursday, February 14, 2019

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The rheumatodermatology interface p. 1
Smitha Prabhu, Mukhyaprana M Prabhu
Rheumatodermatology is an area of clinical medicine, wherein rheumatological and dermatological features dominate in various connective tissue disorders. It can occur as a systemic rheumatic disease where there is major skin manifestation, inflammatory arthropathies, or complications of immunological dysfunction caused by the rheumatological condition or of the immunosuppressants administered. There are also subtle skin signs of rheumatodermatological conditions which are apparent only to dermatologists and significant joint and internal involvement which may be diagnosed only by the rheumatologist. Hence, a liaison between these two specialties is advisable for optimal management of such diseases.
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Overview of diseases in rheumatodermatology p. 3
Sarita Sasidharanpillai
Patients manifesting rheumatodermatology diseases may seek the services of dermatologist or rheumatologist, based on the predominant symptom. Awareness regarding the varied clinical presentations is essential for proper diagnosis and management, often necessitating interdisciplinary care. Here, we comprehensively discuss the individual autoimmune and inflammatory conditions that are classified under the category of rheumatodermatology diseases.
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Systemic lupus erythematosus and overlap: A clinician perspective p. 12
Sanket Shah, KG Chengappa, Vir Singh Negi
Autoimmune inflammatory rheumatic diseases, also termed as autoimmune collagen vascular diseases, as the name suggests are the group of illness arising from a combination of loss of tolerance to self-antigens and shifting of the immune system into self-destructive overdrive. These are commonly classified under six mutually exclusive diseases which include systemic lupus erythematosus (SLE), systemic sclerosis (SSc), dermatomyositis, polymyositis, rheumatoid arthritis (RA), and primary Sjögren syndrome, the so-called definitive connective tissue diseases. Undifferentiated and mixed connective tissue disease and overlap syndrome have also been added to the classification. An initially undifferentiated connective tissue disease may later evolve into a differentiated connective tissue disease. Here, we define the various connective tissue diseases and elaborate more upon SLE and its overlap, including the overlap of RA (RHUPUS).
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Dermatomyositis: A dermatological perspective p. 18
Deepthi Ravi, Smitha Prabhu
Dermatomyositis (DM) is an autoimmune idiopathic inflammatory myopathy which has distinctive skin lesions, specific autoantibodies, and most importantly, symmetrical proximal muscle weakness and muscle inflammation of subacute onset. Some cases of DM present with only characteristic skin lesions without muscle disease and referred to as clinically amyopathic DM. Characteristic skin lesions include violaceous discoloration around the eyelids (heliotrope rash), erythematous rash over the face, erythematous scaly papules over the interphalangeal and metacarpophalangeal joints (Gottron's papules), erythema over the same joints (Gottron's sign), photosensitive pruritic erythema over the anterior chest and neck (V-sign), erythema extending to the shoulders and back (Shawl sign), distorted cuticles with dilated capillary loops over the proximal nail folds, and hyperkeratotic fissured skin over the palms and lateral aspect of the fingers (Mechanic's hands). Causes for mortality and morbidity in DM include malignancy, respiratory disease, and cardiac disease. After ruling out internal associations, Mangement involves photoprotection and medications including systemic corticosteroids, antimalarials, mycofenolate mofetil, biologicals and IV immunoglobulins, depending upon patient parameters.
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Skin in rheumatoid arthritis and seronegative arthritis p. 23
Pragathi Sankineni, BV Meghana
Rheumatoid arthritis is a multisystem inflammatory disorder affecting the joints, soft tissue, as well as extraarticular sites like the skin. Cutaneous manifestations occur in up to 40% cases and vary from specific to nonspecific lesions. Specific changes consist of rheumatoid nodules, neutrophilic dermatoses such as palisaded neutrophilic granulomatous dermatoses, rheumatoid neutrophilic dermatoses, pyoderma gangrenosum, and Sweet's syndrome; nonspecific changes include skin atrophy, wrinkling, palmar erythema, and Raynaud's phenomenon. Seronegative arthritis is a group of chronic inflammatory arthritis, which is typically negative for rheumatoid factor, and is often associated with HLA-B27. There is asymmetric peripheral polyarthritis with sacroiliitis and is often associated with cutaneous, ocular, genitourinary, and gastrointestinal abnormalities. Psoriatic arthritis, reactive arthritis, inflammatory bowel disease-associated arthritis, and ankylosing spondylitis are the major conditions seen in this group.
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Demystifying antinuclear antibodies and other serological tests in dermatology practice p. 29
Anupam Berwal, Indira Bairy, Akshita Gupta
The presence of various autoantibodies in patients' sera is the most common marker of autoimmune diseases, and detection of these antinuclear antibodies (ANAs) aid the diagnosis of several autoimmune disorders in clinical practice; this review article is on ANA assays and other serological tests, specifically the ANA and their interpretation, correlation with its applicability in the dermatology practice.
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Management of systemic sclerosis: A dermatologist's approach p. 34
Deepthi Ravi, Smitha Prabhu
Systemic sclerosis (SSc) is an autoimmune connective tissue disease affecting the blood vessels, skin, and internal organs. The main pathogenic mechanisms are vascular dysregulation, tissue fibrosis due to collagen and extracellular protein deposition, and autoantibody production due to immune dysfunction. The treatment also targets these mechanisms. Various criteria including the American College of Rheumatology and the European League against Rheumatism are laid down for the clinical diagnosis of scleroderma, and treatment is tailored to the systems involved. In the initial stages of the SSc, immunosuppressants are more useful, whereas in the later stages, antifibrotic therapies are important. Vasospasm and endothelial dysfunction are seen in all stages of the disease, and hence, vascular therapies are needed throughout the course of the disease. Special care should be taken to rule out gastrointestinal, pulmonary, and renal system involvement if the primary treatment is by a dermatologist.
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Biologicals in the management of rheumatodermatologic conditions and beyond p. 41
CB Mithun, B Harikrishnan
Biologicals are synthesized from living cells by biotechnology methods and typically include monoclonal antibodies and fusion proteins targeted against pathogenic cytokines, B or T cells, or its receptors. A biosimilar is a cheaper, manufactured product which is almost the same as biological. Appropriate patient selection is the key consideration before starting biologicals. Screening for tuberculosis is a must, except in case of rituximab. Tumor-necrosis-factor alpha inhibitors, interleukin (IL)-17A antagonists, anti-CD6 monoclonal antibodies (mAbs), and anti-IL-6 mAbs are discussed here for various indications.
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Disease-modifying antirheumatic drugs – Old and new: A brief overview p. 47
Vidya Divakar Baliga, Raghuveer S Prabhu
Rheumatological disorders comprise a vast subset of conditions with differing manifestations but overlap in pathogenesis. Disease-modifying antirheumatic drugs (DMARDs) are a diverse group of medications which aim at the various pathogenic factors leading to these disorders. DMARDs are of three broad subtypes: the conventional synthetic DMARDs, the biologicals, and Janus kinase inhibitors. Here, we give a brief overview of the various DMARDs with an emphasis on their practical use.
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Interesting cases in autoimmune connective tissue diseases: Clinical pearls for diagnosis and management p. 57
Sajjan N Shenoy
Rheumatological diseases are multisystem in nature and skin is often involved, and mirrors the internal involvement which affords us insight into the disease, both from a diagnostic point of view and also from a pathophysiological point of view. A few clinical cases which were initially perplexing, but subsequently diagnosed as mixed connective tissue disease, dermatomyositis, and polyarteritis nodosa, are being discussed here to highlight this point.
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Foot eczema and footwear dermatitis: Role of patch test using Indian standard series and footwear series p. 62
Vijay Aithal, Mareen Ann Jacob
Context: Foot eczema is a common complaint encountered in dermatology outpatient department. Footwear dermatitis forms an important exogenous cause of foot eczema. Patch testing helps in identifying possible allergens causing footwear dermatitis. Aims: This study aims to study the clinical profile of foot eczema and to evaluate patch test results in these patients. Subjects and Method: Fifty patients with foot eczema were included in the study and underwent patch testing with Indian standard series and footwear series. Patch test results were read as per International Contact Dermatitis Research Group guidelines. Statistical Analysis Used: Descriptive data are given as mean standard deviation. Differences between patients were assessed by unpaired “t”-test and frequency of parameters by the Chi-square test. Linear regression analysis was used, and correlation coefficients were calculated by Pearson's method. P <0.05 was considered statistically significant. Results: Foot eczema was most common in the 18–29 years of age group (48%), with a male:female ratio of 1.78:1. Office workers (50%), followed by students (24%) were the common occupational groups affected. Allergic contact dermatitis (ACD) (60%), followed by discoid (10%) and forefoot eczema (10%) were the common morphological types. Parthenium (13.8%), diphenylguanidine (10.3%), and potassium dichromate (10.3%) were common allergens seen. Parthenium was the most common allergen identified by patch testing in our study. Conclusion: Patch testing may be used as a valuable and safe additional tool to aid the clinician's diagnosis and help in the treatment of ACD.
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Association of lichen planus with dyslipidemia: A comparative, cross-sectional study p. 68
Neema Azeez, Neelakandhan Asokan
Context: Lichen planus (LP) is an idiopathic T-cell-mediated inflammatory disorder. Chronic inflammation may result in derangement of lipid metabolism. Some studies have shown that prevalence of dyslipidemia is more among patients with LP, whereas other studies have not supported this hypothesis. Aims: The aim of this study is to find out if there is any association between LP and dyslipidemia. Settings and Design: The study was conducted at the dermatology outpatient department of a tertiary care hospital; this was a comparative, cross-sectional study. Subjects and Methods: Forty-seven patients with LP aged 20 years or more attending the dermatology department of a tertiary care hospital were recruited for the study. Comparison group consisted of 47 age- and sex-matched patients with skin infections of <1 month duration. Fasting lipid profile of all participants was estimated. Proportion of patients with dyslipidemia in both groups was compared using Chi-square test. Student's t-test for equality of means and Levene's test for equality of variances were used to compare the lipid profile values in both groups. Statistical Analysis Used: Chi-square test, Student's t-test for equality of means, and Levene's test for equality of variances. Results: Dyslipidemia was observed among 30 (63.8%) patients in the LP group and among 23 (48.9%) patients in the comparison group (P = 0.145; odds ratio = 1.84; 95% confidence interval = 0.81–4.2). There was no significant difference in mean serum cholesterol (P = 0.096), triglycerides (P = 0.318), high-density lipoprotein (HDL) (P = 0.901), and low-density lipoprotein (LDL) (P = 0.077) between the two groups. Levene's test of equality of variances showed that differences in the variability between patients in the LP and in the comparison group were significant for serum cholesterol values (P = 0.036), but not for serum triglycerides (P = 0.821), HDL (P = 0.343), and LDL (P = 0.841). Conclusions: Although the prevalence of dyslipidemia was more among patients with LP, it was not significant at 5% level.
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A cross-sectional study of cutaneous changes in patients with acquired thyroid disorders p. 72
Anupama Bains, GR Tegta, Deepak Vedant
Background: Thyroid disorders are quite common in India. Thyroid hormone affects the skin and its appendages, and the cutaneous manifestations are more notable during deficiency or excess state. Apart from this, thyroid diseases are accompanied by various autoimmune dermatoses. Aim: The present study was designed to assess the dermatological manifestations in patients with thyroid disease. Materials and Methods: This was a hospital-based, cross-sectional, descriptive study conducted in a tertiary care center in Northern India over a period of 1 year. A total of 126 newly diagnosed patients with acquired thyroid disorders were enrolled in the study. All the patients were assessed for cutaneous, hair, nail changes, and associated autoimmune dermatological diseases. Results: Out of 126 patients, 113 had hypothyroidism and 13 had hyperthyroidism. Females outnumbered males in both the study groups. Some patients had more than one dermatological manifestation. The most common dermatological manifestation in hypothyroid patients was generalized xerosis (67.25%), followed by diffuse hair loss (47.78%) and coarse hair (44.24%). In hyperthyroid patients, the most common manifestation was thin soft hair (61.53%), followed by warm skin (53.84%) and Jellinek's sign (38.46%). Chronic urticaria was the most common associated autoimmune dermatological disease in both the study groups. Conclusion: In some instances, the initial and the most prominent complaint of the patient is related to alterations in the skin, and therefore, the dermatologist is at times being the first physician consulted. Identifying the endocrinopathy is very important so that the patients might receive corrective rather than symptomatic treatment.
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Facial frictional melanosis in Indian patients: Defining the entity p. 78
Sharad D Mutalik, Suresh V Pethe, Balkrishna P Nikam, Yashashree D Rasal
Background: Facial melanosis in tropics presents as a diagnostic and therapeutic challenge. We report characteristic patterns of facial pigmentation following vigorous rubbing or cleaning of the face in Indian patients. Awareness of the condition shall guide the clinician to a specific diagnosis. Objective: To study clinicohistopathological profile and patterns of facial frictional melanosis (FFM). Materials and Methods: A multicenter clinicohistopathological hospital-based cross-sectional case descriptive study of sixty patients with characteristic patterned facial melanosis underwent a detailed history taking and clinical examination over a period of 5 years. Biopsy specimens of thirty patients were analyzed for histopathology with hematoxylin-eosin stain. Ten biopsy specimens were also processed for both Fontana Mason and Congo red staining. Results: Sixty patients (males n = 48, females n = 12) with typical clinical features of FFM were studied. Ages of patients varied from 16 to 68 years. Patients on direct questioning confirmed history of vigorous rubbing with hand/handkerchief to clear the face of sweat and grime. Pigmentation was distributed symmetrically over the bony prominences with several characteristic patterns. Histology showed epidermal hypermelanosis, dermal melanin incontinence, and consistent absence of amyloid deposits. Conclusion: We present characteristic facial melanosis in Indian patients due to friction as a specific type of benign friction melanosis. We aim to bring to notice; friction as a distinct etiology of patterned facial hyperpigmentation.
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Evaluation of chitosan impregnated with silver nanoparticles in the treatment of chronic venous leg ulcer: An open-label controlled study p. 84
Maha A Elgayyar, Ahmed Abdelmoneim, Khalid Mowafy, Moustafa A Elsaied, Mqdad Hasan Faqe, Mohammad Ali Gaballah
Background: The treatment of chronic venous leg ulcer (CVLU) is a major challenge. Much scientific advancement was made. Chitosan, derived from N-deacetylation of chitin, has been successfully used to promote wound healing. Silver nanoparticles (AgNPs) are used as bactericides. The aim of this work is to evaluate the efficacy and safety of chitosan alone or that impregnated with AgNPs compared to traditional compression bandage dressing in the treatment of CVLU. Materials and Methods: Thirty-eight CVLU patients completed the treatment for 3 months. They were treated with compression bandage and categorized into three groups: Group A included 12 patients used chitosan impregnated with the AgNPs, Group B included 11 patients used chitosan alone, and Group C included 15 patients used compression bandage alone. For all patients, routine investigations, lower limbs Duplex ultrasound and bacterial culture and sensitivity from the ulcers before and after treatment were done. Results: The healing of ulcers in the treated groups was mostly apparent in Groups A and C. Conclusions: Chitosan impregnated with AgNPs can be a hopeful treatment for CVLU. However, compression bandage alone is also effective for the treatment of CVLU.
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Myxomatous form of lupus vulgaris in ear: A rare presentation p. 89
C Chandrakala, Gurusami Karuvelan Tharini
Lupus vulgaris is a postprimary, chronic form of cutaneous tuberculosis commonly seen over the extremities and gluteal region in Indian population. It is rarely seen over the ears. Lupus vulgaris occurring in the ear was described as “Turkey ear” in some articles. Lupus vulgaris occurring at the cartilaginous sites such as ears and nose lead to disfiguration. Early diagnosis of lupus vulgaris at these sites and initiation of antituberculous drugs will prevent the complications such as mutilation.
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A case of erythema elevatum diutinum with dapsone hypersensitivity syndrome p. 92
Anirudha Dharnidhar Gulanikar, Shubhangini S Sharma
Erythema elevatum diutinum (EED) is a rare chronic form of leukocytoclastic vasculitis that belongs to the group of neutrophilic dermatoses. The exact pathogenesis of the disease is still unclear. It has been associated with a number of systemic diseases including infections, autoimmune diseases, and both benign and malignant hematologic disorders. We report the case of a 50-year-old woman with complaints of symmetrical lesions on the extensor aspects of bilateral upper and lower limbs and pressure areas for 6 months. This case was difficult to manage because the patient was also hypersensitive to dapsone which is the drug of choice in EED.
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Dermoscopic characterization of dilated pore of winer: Report of two cases p. 96
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit
Dilated pore of Winer is a benign tumor of infundibulum of the pilosebaceous unit. The morphological features of this condition are characteristic enough to allow a clinical diagnosis. It generally presents as an enlarged solitary open comedone-like lesion on the head and neck region or the trunk of elderly individuals. Although the diagnosis is mainly clinical, dermoscopy may be of further assistance. However, to the best of our knowledge, there are no documented dermoscopic features of the classical type of this disorder as in our cases. We report the dermoscopic findings of two cases along with clinical and histopathological correlation.
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Umbilicated lesions in dermatology Highly accessed article p. 99
Aditya Kumar Bubna
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Micropapular sarcoidosis p. 104
Rohan M Patil, Vidyadhar R Sardesai, Trupti D Agarwal
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Dramatic response of cutaneous, nail, and joint symptoms of psoriasis to apremilast p. 106
Meghana Bathina, Amina Asfiya Iqbal, Malcolm Pinto, Manjunath M Shenoy
Apremilast has been available in India for the past 6 months as a therapy for psoriasis. A 31-year-old male patient with a diagnosis of psoriasis with oligoarthritis who was not tolerating methotrexate was treated with apremilast. We noticed a dramatic response to the cutaneous and joint symptom within a month of initiation of the therapy. We also noticed improvement in the nail changes. He tolerated the drug except for an episode of diarrhea that resolved without any intervention. Apremilast is a useful addition to the therapeutic armamentarium of psoriasis and arthritis.
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