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   Table of Contents - Current issue
Coverpage
January-June 2020
Volume 4 | Issue 1
Page Nos. 1-68

Online since Monday, January 6, 2020

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REVIEW ARTICLE  

A bird's eye view of common antiandrogens used by dermatologists Highly accessed article p. 1
Aditya Kumar Bubna
DOI:10.4103/CDR.CDR_5_19  
The use of antiandrogens is gaining significance in dermatology practice these days. Though once considered a domain of endocrinologists and gynecologists, these drugs now constitute an important category while treating a number of dermatologic conditions. A thorough knowledge of these drugs, as well as their applications in dermatology would therefore be of immense value for the practicing dermatologist. This review will throw a bird's eye view on the salient aspects of these drugs and their importance in those conditions, where their usage in applicable.
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ORIGINAL ARTICLES Top

Granulomatous cheilitis: Report of three cases and systematic review of cases and case series reported from India Highly accessed article p. 12
Yugal Kishore Sharma, Shivanti Chauhan, Kirti Deo, Prachi Agrawal
DOI:10.4103/CDR.CDR_29_18  
Introduction: Granulomatous cheilitis (GC) is a rare idiopathic inflammatory disorder characterized by chronic persistent swelling of the lips. Despite a lingering controversy, it remains linked to orofacial granulomatosis and Melkersson–Rosenthal syndrome (MRS). Aim: To systematically review all cases of GC reported hereto from India with the three being reported now, analyzing patients'/disease characteristics, associated diseases, and treatment protocol. Materials and Methods: Using biomedical search engines such as PubMed, Scopus, and Google Scholar, a systemic review of cases/case series reported from India (1994–2018) was undertaken, and data on patients'/disease characteristics, association with other diseases, and treatment extracted discussed and analyzed without subjecting to statistical analysis due to the small population size. Results: The mean age at presentation of these cases (n, 73: Single, 39: Participants of 6 series, 31 plus presently reported, 3) was 29.36 years and at onset was 26.62 years. There was female preponderance of 1.8. Complete triad of MRS was recorded in 8 (10.95%), and oligosymptomatic forms were as follows: GC + facial palsy, 5 (6.85%); GC + fissured tongue, 4 (5.48%); and facial palsy + fissured tongue, 1 (1.37%). Monosymptomatic GC was seen in 55 (75.34%) and upper lip involvement in 29 (39.72%). Conditions associated with GC included Down syndrome, rosacea, granulomatous vulvitis, and pregnancy. None of the cases were associated with Crohn disease and sarcoidosis. Intralesional triamcinolone acetonide (33, 45.21%) was the most common modality of treatment. Conclusion: Cases of GC from India over the past quarter of a century were reported rarely and showed female preponderance. This chronically recurrent entity with variable severity lacks larger studies and randomized controlled trials for optimum treatment.
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A descriptive case-Control study of 100 patients of acanthosis nigricans and its utility to detect metabolic syndrome p. 17
Nisha Prakash, Yadalla Hari Kishan Kumar, PR Belliappa
DOI:10.4103/CDR.CDR_56_18  
Background: Acanthosis nigricans (AN) is a dermatosis that manifests as asymptomatic and symmetrical darkening in intertriginous areas and is associated with endocrine disturbances or malignancy. The features of metabolic syndrome (MetS) include hyperglycemia, hypertriglyceridemia, low high-density lipoprotein (HDL) cholesterol, central obesity, and hypertension. Aims and Objectives: (1) To study the fasting and postprandial blood sugar level, lipid profile, blood pressure, and waist circumference (WC) in patients with AN and compare the values in healthy controls.(2) To determine the association between the presence of benign acquired AN and MetS (biochemical parameters and anthropometric variables). Materials and Methods: A descriptive case–control study with 100 cases of AN and 100 healthy controls without AN was conducted between December 2016 and November 2017 to assess the association between AN and metabolic variables. Results: In this study, out of the 100 cases evaluated, 57% had MetS diagnosed by the National Cholesterol Education Program and Adult Treatment Panel III, of which 35 were females and 22 males. Among 100 cases of AN, 31 had hypertension (P = 0.438), 57 had elevated triglycerides (P = 0.007), 33 had elevated fasting blood sugar (P = 0.061), 76 had decreased HDL cholesterol (P = 0.000045), and 78 had increased WC (P = 0.00463). The association of AN with MetS was highly significant in the study population (P = 0.000017; as P < 0.05-significant; P < 0.01-highly significant). Conclusion: In this study, 57 patients with AN had deranged metabolic variables suggesting the presence of MetS. This study shows that AN could be a marker for MetS. Hence, clinicians should assess patients with AN for metabolic and biochemical parameters to advise regarding lifestyle modification and prevent future cardiovascular complications.
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A clinical study of cutaneous manifestations in patients with chronic kidney disease on conservative management, hemodialysis, and renal transplant recipient p. 23
Ashish Khare, Anirudha D Gulanikar
DOI:10.4103/CDR.CDR_59_18  
Background: The skin acts as an external reflection of renal diseases. The dermatologic disorders in chronic kidney disease (CKD) can be attributed to the etiology, the disease, or the treatment and can markedly affect a patient's quality of life. Aim: The aim is to study the pattern and proportion of cutaneous manifestations in CKD patients on dialysis, on conservative management and in posttransplant patients. Materials and Methods: A cross-sectional hospital-based study was conducted. Seventy-five patients with CKD on hemodialysis, 25 patients with CKD on conservative management, and 20 posttransplant patients were included in the study. All the patients were clinically examined after written consent. Results: At least, one dermatological manifestation was present in every patient included in the study. The most common underlying disease that leads to CKD was diabetes mellitus. The most common manifestation was xerosis seen in 60% patients followed by pruritus seen in 43%, pallor seen in 41% and pigmentary changes seen in 28% patients. Cutaneous infections were seen in 43%, nail changes in 82%, hair changes in 40%, and oral mucosa changes were seen in 38% of patients. Drug-induced cutaneous manifestations were seen in posttransplant patients like acneiform eruptions in 32% of patients followed by hirsutism in 8%, striae in 8%, and hypertrichosis in 4% of patients. Conclusion: The proportion of xerosis, pruritus, pigmentation, and pallor are more common in the dialytic group than nondialytic group. Early recognition and some prophylactic measures can prevent or decrease some of the adverse changes.
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Validation of vitiligo impact scale-22 among North Karnataka population p. 31
Anusha Shivaswamy, Aparna Palit, Arun C Inamadar
DOI:10.4103/CDR.CDR_55_18  
Background: Vitiligo is known to have major psychosocial impact among the sufferers. “Vitiligo impact scale-22 (VIS-22)” is a recently developed specific scale to measure quality of life (QOL) in these patients. It was found effective in evaluating QOL among north Indian patients with vitiligo. Since the effect of vitiligo on QOL is variable, it is prudent to validate VIS-22 in various populations. Aim: This study aims to validate VIS-22 among south Indian patients with vitiligo. Methods: Vitiligo patients with education up to 10th standard were included as cases. Patients suffering from short-term illnesses served as controls. Cases and controls were given visual analog scale (VAS), dermatology life quality index (DLQI), Skindex-16 and VIS-22 to respond at 1st, 2nd, and 12th weeks. The criterion and construct validities of the scales were evaluated using Spearman's correlation coefficient (r). Student's t-test was used for disease specificity of VIS-22. Spearman's rank coefficient, paired t-test, and ANOVA were used to estimate first, second, and third measures of responsiveness, respectively. Results: A total of 153 cases and 155 controls were enrolled. The criterion validity showed strongest correlation with Skindex-16 (r = 0.832) and convergent validity with both DLQI (r = 0.752) and Skindex-16 (r = 0.832). It also showed strong correlation with emotional and functioning domain of Skindex-16 at baseline (r = 0.713 and 0.702, respectively) and at 12 weeks (r = 0.770 and 0.789, respectively). The scales were reliable at baseline and 2 weeks with excellent correlation between scores (r = 0.954). The VIS-22 scores were responsive at week 12 and similarly in VAS, DLQI, and Skindex-16. Conclusion: VIS-22 has vitiligo-specific questions and better QOL measurement properties compared to DLQI and Skindex-16. This study results found VIS-22 to be a valid, highly reliable, and responsive QOL-measurement tool among south Indian patients with vitiligo.
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A modified regimen of rituximab in pemphigus: A retrospective study p. 36
Tanvi Pradeep Vaidya, Jacintha Martis, Ramesh M Bhat, Sukumar Dandekeri
DOI:10.4103/CDR.CDR_22_19  
Introduction: Rituximab is a chimeric monoclonal antibody targeted against CD20 T-cells. It acts by the destruction of autoreactive B-cells. It is a common biologic agent widely used for the treatment of B-cell lymphoma, lymphoproliferative disorders, and inflammatory conditions that are refractory to conventional treatment, such as rheumatoid arthritis. However, various recent studies have shown an increasing number of serious adverse events associated with the use of rituximab, such as serious, often fatal, infusion reactions, infections, rigors, fever, peripheral edema, hypertension, myelosuppression, elevated transaminases, and cardiac failure. Only a few such studies have been performed in Indian patients, where Rituximab is still a new molecule. Aims: The aim of this study is to assess the efficacy and adverse events profile in patients with pemphigus group of diseases treated with rituximab. Materials and Methods: In this retrospective study, we analyzed records of 20 cases of pemphigus who received a modified rheumatoid arthritis (RA) protocol from January 2016 to June 2018, for the efficacy of rituximab as well as for the immediate and late adverse effects encountered with the use of rituximab. Results: It was found that 50% of cases achieved complete remission for the entire duration of follow up. The mean duration of remission was 8.55 months. More than 75% of patients relapsed only after 6 months. Twelve patients (60%) had various infusion reactions such as fever, chills, giddiness, breathlessness, bradycardia, and cyanosis. About 30% of the patients developed late side effects such as onychomycosis and sepsis. One of the patients died due to sepsis. Conclusions: Hence, we conclude that rituximab is still very effective at half the dose in the conventional RA protocol, and although it is a highly efficacious drug, it must be used with great caution, keeping in mind, these catastrophic side effects.
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CASE REPORTS Top

Lip swelling and constipation: Pretest probability of cutaneous signs for crohn's disease in the absence of typical gastrointestinal symptoms p. 42
Maggie L Chow, Minnelly Luu
DOI:10.4103/CDR.CDR_25_18  
We describe a female child in the first decade patient admitted to a children's hospital for lip swelling and constipation who was ultimately diagnosed with Crohn's disease. Her lip swelling resolved after the initial immunosuppression for her Crohn's disease. In this article, we discuss the pretest probability of cutaneous findings associated with inflammatory bowel disease in predicting a diagnosis of Crohn's disease in the absence of intestinal symptoms. Cutaneous findings including linear immunoglobulin A bullous dermatosis, pyoderma gangrenosum, lichen spinulosus, and epidermolysis bullosa acquisita are discussed.
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Co-Occurrence of neurofibromatosis-1 with urticaria pigmentosa: A Coincidental association? p. 46
Nazneen Zulfikar Arsiwala, Arun C Inamadar, Ajit B Janagond
DOI:10.4103/CDR.CDR_37_18  
Neurofibromatosis-1 (NF-1) is a neuroectodermal abnormality characterized by multiple neurofibromas, café-au-lait macules, axillary freckling, and Lisch nodules. Urticaria pigmentosa (UP) is a maculopapular cutaneous mastocytosis due to mast cell hyperplasia. We report a case of NF-1 associated with UP. A 19-year-old male presented with multiple neurofibromas, café-au-lait macules, axillary freckling, and Lisch nodules. He also had UP lesions with positive Darier's sign. A clinical diagnosis of NF-1 with UP was made and confirmed histopathologically. Mastocytosis exhibits mast cell hyperplasia due to C-kit gene mutation. Mast cell mediatiors directly contribute to neurofibroma growth. C-kit receptor abnormality is implicated in the formation of neurofibromas as well as in UP. With possible interconnected underlying pathology of mast cell hyperplasia and increased mast cell mediators in both UP and NF-1, a possible association of NF and UP beyond simple coincidence should be considered.
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Kaposi varicelliform eruption caused by varicella virus in a case of tinea corporis et cruris p. 50
Mudita Gupta, Saru Thakur, Reena Kumari Sharma
DOI:10.4103/CDR.CDR_53_18  
Kaposi varicelliform eruption (KVE) is a disseminated vesiculopustular lesion occurring over a preexisting cutaneous lesion. Although initially thought to be caused by herpes virus 1 and 2, other viruses have also been known to provoke the disease. There are no reports of human herpes virus 3 over tinea infections causing KVE.
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Albendazole and Stevens–Johnson syndrome: A cause p. 53
Aakash Gupta, Balachandra S Ankad, Priyanka Jaju
DOI:10.4103/CDR.CDR_40_18  
Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) represent severe reactions in the skin and the mucous membranes, most commonly caused by drugs. An adult female developed erythematous and dusky red lesions over the body 5 days after oral albendazole. Atypical target lesions sparing the scalp were seen on day 2 of admission with positive Nikolsky sign. A clinical diagnosis of SJS (with 12.1% predicted mortality) was made which correlated with biopsy. The patient responded well to intravenous dexamethasone and oral cyclosporine. The report highlights the drug, albendazole, as a sole factor causing SJS/TEN and warrants further evaluation and subsequently control measures.
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Ross syndrome and diabetes mellitus: An interesting association p. 57
Chetan D Rajput, Sanjay B Gore, Shailesh S Malani, Swagat M Shah
DOI:10.4103/CDR.CDR_33_18  
Ross syndrome is a rare disorder of sweating with a triad of segmental anhidrosis, tonic pupil, and hyporeflexia. Survey of available literature shows scarce reporting of such cases globally and countable number of cases from India. Here, we report the case of a 35-year-old male presented with heat intolerance and all three clinical features of Ross syndrome. Further investigations revealed him to be diabetic. Diabetes was treated with insulin and oral hypoglycemics. The patient had increased comfort in hot and humid climate and slight improvement in sweating over anhidrotic areas after strict diabetic control. The association of diabetes mellitus and Ross syndrome in the index case is quite interesting and hitherto not reported.
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Cutaneous mantle cell lymphoma: A rare case report p. 61
Salwa Bano, Veena Ramaswamy, BN Tejaswini, Chaitra Chandrashekar
DOI:10.4103/CDR.CDR_58_18  
Cutaneous mantle cell lymphoma (MCL) is a very rare entity with very few cases reported till date. We report a case of 69-year-old man with generalized lymphadenopathy who was diagnosed with mitotically active B-cell lymphoma and a year later developed multiple large maculopapular skin rashes which on biopsy showed infiltration of large atypical blast-like cells in the skin and on immunohistochemistry was in favor of MCL-blastoid variant. Skin involvement is rare in MCL, although in some cases, cutaneous manifestations are the first symptom. Skin involvement suggests a disseminated disease and is often associated with blastoid cytological features. Awareness of skin manifestations of MCL is crucial for dermatologists and hematologists for prompt diagnosis and timely treatment. Moreover, it has a dismal prognosis and shows a poor response to standard treatment.
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LETTERS TO EDITOR Top

Metabolic syndrome in patients with psoriasis: A hospital-based case–control study p. 64
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/CDR.CDR_31_18  
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Unmasking the casts: The true nature of pseudonits p. 65
M Sneha, AS Savitha, Nagesh Tumkur Subbarao
DOI:10.4103/CDR.CDR_11_19  
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Lichenoid psoriasis: A distinct morphological entity p. 67
Naveen Kumar Kansal, C Divyalakshmi, Aditi Dhanta
DOI:10.4103/CDR.CDR_15_19  
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