Switching to secukinumab in difficult-to-treat psoriasis recalcitrant to methotrexate, cyclosporine and leflunomide, in a tuberculosis-endemic country.

Several biological agents have been approved for the treatment of recalcitrant psoriasis. However, there is a lack of a consensus algorithm guiding the drug selection for patients who have failed conventional drugs. In cases not improving with cyclosporine, direct switching to a biological therapy usually leads to a disease flare owing to increased production of interleukin (IL)-17A. Thus, secukinumab, a rapidly acting anti-IL-17A drug, may be ideal in such situations.

Recalcitrant alopecia areata responsive to leflunomide and anthralin-Potentially undiscovered JAK/STAT inhibitors?

Several treatment modalities are available for the management of alopecia areata (AA); however, no therapy is universally effective and treatment can be frustrating in severe cases, with low response and high recurrence rates. Recent studies show that the JAK/STAT pathway plays a central role in the pathogenesis of this disease by determining the crosstalk between the infiltrating CD8+ T cells and the hair follicles, suggesting a role of JAK inhibitors in the treatment of AA. However, reports on the off-label use of these more expensive targeted agents have shown variable results. We present a case of a child with recalcitrant ophiasis-pattern AA who had failed steroid therapy and was treated successfully with leflunomide and anthralin, possibly by the synergistic effect on the JAK/STAT pathway inhibition, and we propose this combination could be a cost-effective therapeutic option for recalcitrant AA.

An unusual case of noma caused by Klebsiella pnuemoniae and its management.

Noma or cancrum oris is an orofacial gangrene causing progressive mutilating destruction of the infected tissues. It mainly affects malnourished children with poor oral hygiene and concurrent debilitating systemic illnesses. It is a polymicrobial infection and borrelia vincentii and fusobacterium are the most important pathogens known. We present a case of a boy aged 2.5 years with noma where klebsiella was grown and was the initial cause of failure of empiric therapy.

Lymphocutaneous Sporotrichosis Treated with Potassium Iodide with Development of Subclinical Hypothyroidism: Wolff-Chaikoff Effect?

Sporotrichosis is a subcutaneous mycotic infection caused by Sporothrix schenckii that is acquired by traumatic implantation. The diagnosis is established by demonstration of fungal elements on histopathology and culture. Potassium iodide, azole antifungals, and terbinafine are the treatment options available. In this article, we report a 60-year-old female with lymphocutaneous sporotrichosis that responded well to potassium iodide. However, subclinical hypothyroidism (Wolff-Chaikoff effect) was encountered as a side effect of therapy which was managed with thyroxine replacement. Knowledge about the Wolff-Chaikoff effect (WCE) is important for the dermatologist and reinforces the need for screening and monitoring of thyroid stimulating hormone (TSH) in patients where long duration therapy is being planned.

Bilateral Lichen Striatus: A Case Report with Review of Literature.

Lichen striatus is a self-limiting dermatosis presenting with sudden eruption of lichenoid papules along the lines of Blaschko. A 5-year-old girl presented with asymptomatic hypopigmented linear lesions over both upper limbs. The histopathological examination revealed spongiosis, vacuolar alteration of the basal layer and lymphocytic exocytosis with a mild-to-moderate perivascular mononuclear infiltrate in the dermis. Lichen striatus was diagnosed based upon the characteristic clinical and histopathological findings. The pathogenetic mechanism of bilateral lichen striatus is unknown at present, however, a somatic mutation in two different clones of cells can be a possibility.