Comparison of topical methylprednisolone 1% versus placebo in stevens – johnson syndrome and/or toxic epidermal necrolysis.

Objective: To study the efficacy of topical methylprednisolone compared with placebo in patients with Stevens-Johnson syndrome (SJS) and/or toxic epidermal necrolysis (TEN). Methods: Thirty-six patients were prospectively studied at Siriraj Hospital. The clinical severity score for ocular involvement was classified as mild, moderate and severe. In 12 patients with moderate severity, 1% methylprednisolone eye drop was added four times daily in one eye and 0.5% normal saline as placebo in another eye for one week. In 2 severe cases, these medications were added every 2 hours till bedtime for one week and four times daily for another week. Results: The average age of 14 patients was 50 ± 16.2 years (± SD), with female preponderance (12). Common precipitating factors were carbamazepine, nevirapine, phenytoin and dimenhydrinate. The common associated diseases were HIV. Five patients were not given systemic corticosteroid due to infection, and minimal skin involvement. The total severity score change in each group was the same at one month. In an average of 7.6 months follow up, most patients recovered normal appearance except for two eyes of the placebo group and one eye of the methylprednisolone group. The percentage of dry eye in the Schirmer test and the rose bengal score in the topical methylprednisolone eyes were not significantly less than in the control eyes. However, less tear production was statistically significant in patients with systemic corticosteroid. Conclusion: Topical corticosteroid might be used cautiously in early stages of SJS or TEN.

Immunohistochemical study for the diagnosis of Alport's syndrome.

BACKGROUND: Alport's syndrome (AS) is the most common cause of inherited glomerular disease in Thailand. The majority of cases show X-linked inheritance, which is caused by mutations in the gene coding for the alpha5 chain of type IV collagen in the glomerular basement membrane (GBM) and epidermal basement membrane (EBM). Such mutation usually leads to a reduction in protein amount, thus, immunohistochemical studies have been considered in diagnostic evaluation. OBJECTIVE: To study the expression of alpha[IV] collagen chains in the skin as an alternative approach to diagnose AS. MATERIAL AND METHOD: Eleven unrelated probands with proven AS, 7 relatives with abnormal urinalysis, 4 suspected individuals, and 8 normal controls were enrolled. A punch skin biopsy and immunofluorescence staining of the tissue specimens for alpha1, alpha3 and alpha5[IV] collagen chains was performed. RESULTS: The alpha5[IV] chain was absent in the EBM in all male AS patients while a discontinuing pattern was observed in all females except one. The findings are specific for AS with a sensitivity of 91%. Studies in relatives and suspected individuals also confirmed the advantage of this approach as demonstrated by the absence and discontinuation of alpha5[IV] staining in all males and females, respectively. We also analyzed their expressions in the kidney tissue and demonstrated abnormal alpha3 and alpha5[IV] staining in five of six samples. CONCLUSION: Immunohistochemical study of the skin should be used as a screening method in patients suspected of AS, as it is much less invasive. Moreover, it is a useful adjunct to conventional examination of biopsied renal tissue.

Direct immunofluorescence study in Thai patients with scleroderma.

OBJECTIVE: Previous reports of direct immunofluorescence (DIF) studies of the skin biopsies in scleroderma were either negative or positive at various percentages and patterns. The present study was designed to evaluate the positive yield and pattern of DIF in Thai patients with scleroderma and its possible clinical correlation. MATERIAL AND METHOD: Twenty-two patients with localized or systemic sclerosis, who attended the Department of Dermatology, Siriraj Hospital, from 1996 to 2002, were enrolled in the present study. Skin biopsy was performed for DIF studies. RESULTS: Nine out of 22 patients were diagnosed with systemic sclerosis (SS), eleven with morphea, and two with overlapping syndrome. Fifteen of 22 patients (68%) had positive DIF findings; seven of nine (78%) patients with SS, six of eleven (55%) patients with morphea and two of two (100%) with overlapping syndrome. The common sites of deposit in SS, morphea and overlapping syndrome were dermo-epidermal junction and epidermal nuclei. The common immunoreactant deposit in all groups was IgM. There was no significant difference in the comparison of DIF findings with duration of biopsy lesion, clinical correlation, and the positive result of serum antinuclear antibody (ANA) in the three groups of patients. CONCLUSION: Positive DIF yield in the present study was higher than previous reports from Western countries. Similar to the study reported from Western country, there was no statistical significant difference in comparison of DIF findings with the duration of lesion, clinical correlation, and the positive result ofserum ANA in our three groups of patients. However; patients with SS had a tendency to give more frequently positive ENS and DEJ deposits than those with morphea.

Prevalence of onychomycosis in patients with autoimmune diseases.

BACKGROUND: Onychomycosis is the most common nail disorder in adults. Many studies reported a higher prevalence of onychomycosis among particular patients, such as those with diabetes, poor peripheral circulation or immunosuppression. However, studies of the prevalence of onychomycosis in autoimmune patients who carry many of these predisposing factors have been limited OBJECTIVE: Study the prevalence of onychomycosis in autoimmune compared to non-autoimmune female patients. MATERIAL AND METHOD: A cross-sectional study of the prevalence of onychomycosis in autoimmune patients and non-autoimmune female patients visiting a dermatology clinic over a period of 18 months. One hundred and sixty-five female autoimmune patients were enrolled. RESULTS: The prevalence of onychomycosis in autoimmune patients was 10.2% (95%CI 6.5%, 15.9%) compared to 6.7% (95%CI 3.8%, 11.6%), in non-autoimmune patients (p > 0.05, 2-sided). Of vesiculobullous patients, mainly presenting with pemphigus and who were mostly on immunosuppressive medication, 24% had onychomycosis [p = 0.013; OR 4.39 (95%CI 1.27, 14.89)]. CONCLUSION: Exposure to humid microenvironments was an important factor in the occurrence of onychomycosis (p < 0.05, 2-sided). However, the number of patients with each individual disease was too small to conclude a prevalence of onychomycosis in conjunction with these individual cutaneous autoimmune diseases.

Drug eruptions at five institutes in Bangkok.

The study was performed in five hospitals in Bangkok for a period of one year. All in- and outpatients who developed drug eruption from January to December 2001 were enrolled into the study. Physical examinations and complete history-taking were performed by one of the authors. A skin biopsy was done to confirm the diagnosis in every suspected case. Oral challenge test was performed to obtain a definite diagnosis only in some patients with informed consent. Among 212 patients, the most common causative drugs were antimicrobial agents with cephalosporin group in the highest rank. Maculopapular rash was the most common type of drug eruption followed by urticaria and photosensitivity reaction. It was concluded that antimicrobial agents were the predominant causative agents and maculopapular eruption was the most frequent clinical manifestation. New kinds of antimicrobial agents, anti-inflammatory drugs and lipid lowering agents could cause various patterns of drug eruption.

Cutaneous leukocytoclastic vasculitis: the yield of direct immunofluorescence study.

BACKGROUND: Leukocytoclastic vasculitis (LCV) is a clinico-pathological entity. Previous direct immunofluorescence study (DIF) studies of vasculitis showed positive findings mainly in the early stage of the disease. OBJECTIVE: To study the positive yield and patterns of DIF in patients with various stages of LCV. DESIGN: One hundred patients with LCV who attended the Department of Dermatology, Siriraj Hospital from 1997 to 2000 were enrolled in the study. RESULTS: The study showed immunoreactive deposits in blood vessel walls in 76 cases (76%). Forty seven per cent of patients showed immunoreactant deposit only in superficial blood vessel walls, 3% had deposits only in deep blood vessel walls. Superficial and deep blood vessel wall deposits were seen in 26%. Dermo-epidermal deposit in addition to blood vessel wall deposit was found in 39%. The most common immunoreactive deposit was C3 (71%), followed by IgM (35%), IgA (12%) and IgG (8%) respectively. The age of the skin lesions at the time of biopsy ranged from 1 to 7 days. 82% of patients with one day old lesions showed immunoreactive deposits in the blood vessel walls and 74% of the group with lesions aged 2-7 days at the time of biopsy showed immunoreactive deposits in the blood vessel walls. CONCLUSION: The present study showed a 76% positive yield for DIF study in patients with LCV when biopsies were performed within one week of onset. There was a tendency for the percentage of positive DIF results to decline when the biopsy was performed on lesions that were more than 1 day old.

Urticaria and angioedema in Siriraj medical students.

The present study aimed to investigate the current prevalence of urticaria with or without angioedema among Siriraj medical students, the possible causative agent(s), the association between a history of atopy, behavior of patients seeking treatment and natural course. A cross-sectional study was conducted among 428 Siriraj medical students, Mahidol University in October, 2001. The study showed the prevalence of urticaria and angioedema to be 51.6 per cent and 19.6 per cent respectively, coexisting in 13.6 per cent but urticaria alone occurred in 38 per cent and angioedema alone in 6 per cent. There was an equal sex distribution. Acute urticaria (93.2%) was more prevalent than chronic urticaria (5.4%), and the acute intermittent type was the most common. Heat, inhalants, and contactants were more often suspected causes than food or drug allergy identified in both forms. More than half the urticaria subjects treated themselves by buying over-the-counter drugs (66%) and the remainder waited for spontaneous remission (49%) with a low percentage seeking medical advice (24% from a general practitioner, 14% from a dermatologist). An atopic history was not a major underlying factor for urticaria. Most patients with acute urticaria were free of symptoms after 3 weeks. Cases with chronic urticaria who were completely healed had a mean disease duration of 14.2 weeks. However, cases with chronic urticaria who had never had a long hive free period since the onset of the disease until the time of the study had a mean disease duration of 6 years. These findings may be useful to help educate affected persons and improve public awareness in order to prevent and manage this disease.

Disseminated penicilliosis marneffei in immunocompetent hosts.

Two cases of disseminated Penicilliosis marneffei are reported; both were middle-aged female patients from the central part of Thailand who presented with multiple cystic skin lesion. Their systemic symptoms included chronic fever, weight loss, malaise, anemia, cervical lymphadenopathy and osteolytic bone lesions. They had no underlying disease causing immunosupression and both were HIV-negative. Skin manifestations occurred frequently in disseminated penicilliosis and abscesses were the most common manifestation in HIV-negative patients whereas umbillicated papules were common in HIV-positive ones. A biopsy from the skin lesions was good specimens for histopathological study and frequently yielded positive culture results. The characteristic histopathological feature is granulomatous inflammation with macrophages containing yeast-like organisms with septa which show a lack of budding. The characteristic mycologic feature of P.marneffei is a thermally dimorphic fungus which produces a mycelial phase colony appearing within 2 days at room temperature (25-30oC) and which produces a bright, purple-red, water-soluble pigment into the surrounding agar. The yeast form grows at 37oC as a whitish colony produced in 4 days and this produces less red pigment compared with the mycelial form. The first case was treated with oral itraconazole intermittently as a result of multiple recurrent episodes until she died of the disease after one year. The second case was treated with amphotercin B intravenously followed by oral itraconazole with a satisfactory result.

Etiologic agents of cutaneous infectious granuloma: 2 year-experience from granuloma clinic, Siriraj Hospital.

Etiological diagnosis of cutaneous infectious granuloma is difficult to achieve and leads to difficult in patient management. We proposed to search for etiologic agents by special stain of histologic sections, cultural method and PCR technique for tuberculous and non-tuberculous mycobacteria. The skin biopsy specimens were obtained from dermatologic patients who attended Granuloma Clinic, Siriraj Hospital from January 1994 to December 1996. Sixty-nine cases of mixed cell granuloma were found during the 2-year-period. The causative agents had been found in 45 cases (65.22%). Mycobacterial infections were documented in 25 cases. Five cases of tuberculous infection were diagnosed by PCR method. Non-tuberculous mycobacterial infections were diagnosed by cultural method in 14 cases and the other 6 cases were diagnosed by acid-fast stain in histologic section alone. Actinomycotic mycetoma were diagnosed in 4cases. Fungal infections were documented in 16 cases, which caused by hyaline fungi 7 cases and dematiaceous fungi 9 cases. About one-third of all cases (24 cases) the etiologic agent could not be identified.