Evaluation of Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio in Chronic Plaque Psoriasis.

Background: Psoriasis is a common inflammatory dermatological condition and affects 2-3% population worldwide. Psoriasis area and severity index (PASI) and body surface area (BSA) are two commonly used scales used to measure disease severity in psoriasis patients. However, these scales are plagued by weaknesses as inter-observer variation and insufficient evaluation of micro-vascular inflammation. Thus, it is necessary to have an objective and simple measure of the severity of inflammation. The ratio of neutrophils-to-lymphocytes (NLR) and platelets-to-lymphocytes (PLR) are simple and inexpensive markers of systemic inflammatory response that can be measured as part of a complete blood count and are already used in the setting of inflammatory diseases. The utility of the NLR and PLR in psoriasis however, remains relatively unexplored. Aims and Objectives: The present study was undertaken to assess if NLR, PLR and C-reactive protein were altered in chronic plaque psoriasis patients as compared to controls and also to determine correlation of NLR and PLR values with disease severity as measured by PASI. Methods: This case control study consisted of equal numbers (45 each) chronic plaque psoriasis patients and control subjects. The subjects were evaluated by way of history taking, clinical and blood examination. Thereafter, the results were tabulated and examined statistically. Results: Our study results indicate that psoriasis patients tended to have a higher neutrophil count, lymphocyte count, NLR and C-reactive protein in comparison the control subjects (P < 0.05). Conclusion: We concluded that such easily available and low cost indices of systemic inflammation are raised in psoriasis patients and are positively correlated with the severity of involvement. They can thus not only be used to monitor the effect of systemic drugs in psoriasis.

Comparative Effectiveness and Safety of Methotrexate Versus PUVA in Severe Chronic Stable Plaque Psoriasis.

BACKGROUND: Psoriasis is a chronic, inflammatory, immune-mediated, debilitating skin disease affecting approximately 2%-3% of the global population. Various treatment modalities are available for extensive psoriasis which include methotrexate, cyclosporine, retinoids, oral PUVA therapy, and biologic agents. AIMS AND OBJECTIVES: The aim of this study was to compare the effectiveness and safety of methotrexate vs. PUVA in severe chronic plaque psoriasis with BSA >20%. MATERIALS AND METHODS: A randomized open-label clinical study was performed. Sixty patients with extensive stable plaque psoriasis were recruited in the study. Thirty patients received methotrexate at a dose of 0.4 mg/kg up to a maximum of 15 mg/week and the rest 30 were treated by PUVA, 8-methoxy psoralen tablet (20 mg) followed by UVA started at the dose of 1 j/cm2 thrice weekly with an increment of 20% dose every third sitting until 2.5 j/cm2 is reached. Both forms of treatment were continued for 10 weeks or until PASI 90 achieved, which-ever was earlier. Clinical examination, blood investigation, PASI scoring, and photograph were repeated in serial intervals during the study. At the end of study, the data were compiled, tabulated, and analyzed. RESULT: In the PUVA group, 90% achieved PASI-50 and 63.33% achieved PASI-90, in the methotrexate group all patients achieved both PASI-50 and PASI-90. Methotrexate acted significantly faster than PUVA in disease clearance. In the methotrexate group decreased platelet count in 13.33% patients, decreased hemoglobin (<10 gm/dl), elevated liver enzyme, each of these developed in 10% of patients. In the PUVA group, no serious side effects were observed. CONCLUSIONS: Methotrexate is more efficacious with lesser incidence of subjective complications and more incidence of laboratory complications compared to PUVA in extensive plaque psoriasis.

Early-Onset Versus Late-Onset Psoriasis: A Comparative Study of Clinical Variables, Comorbidities, and Association with HLA CW6 in a Tertiary Care Center.

Background: Psoriasis is a chronic inflammatory diseaseresulting from a complex interplay of genetic and environmental factors affecting the skin, nail and joints. Two distinct types of psoriasis are said to exist (i) early onset psoriasis (EOP), beginning before the age of 40 years and (ii) late onset psoriasis (LOP), beginning ≥40 years; with the presence of Human lymphocyte antigen (HLA) Cw6, present in majority of patients with early onset. Several studies demonstrated clinical and genetic differences between EOP and LOPamong European and East Asian populations. Lack of similar study in the Indian population has prompted us to undertake the present work. Aims and Objectives: (i) To compare the clinical patterns of early onset and late onset psoriasisin patients attending the Dermatology outpatientdepartment (OPD) and admitted in the in-patient department (IPD). (ii) To analyze the association age of onset with presence of HLA Cw6. Materials and Methods: It was an institution-based, descriptive, cross-sectional study. Consecutive patients with psoriasis at the OPD and IPD of the department of Dermatology during the study period, were recruited in the study after obtaining informed consents. Detailed history was obtained regarding the disease, co-morbidities and complications. Through physical examination was carried out, PASI was calculated and blood samples were drawn fromconsenting adult patients (age>/=18 years) to study the presence of Cw6. Results: The study population (n=250) wasbroadly divided into "Early onset psoriasis(EOP)" (n=138) and Late onset psoriasis (LOP)" (n=112).Significant higher occurrence of positive family history, nail involvement and koebnerization were found in EOP, but such differences were absent considering the types, patterns, joint involvement, severity and HLACW6 positivity. Conclusion: This study supports the concept of two subtypes of psoriasis based on age of onset showing different clinical and evolutionary features.

Azathioprine in autologous serum skin test positive chronic urticaria: A case-control study in a tertiary care hospital of eastern India.

CONTEXT: Urticaria, also referred to as hives or wheals is a common and distinctive reaction pattern characterized by spontaneous eruption of wheals. About 30-50% of patients categorized as idiopathic urticaria have autoimmune urticaria, needing immunosuppressive agents. Immunosuppressive agents are either too costly or have serious side effects. Azathioprine seems to address both these issues, being less costly. AIMS: The aim was to evaluate the role of azathioprine in autologous serum skin test (ASST) positive chronic urticaria (CU). SETTINGS AND DESIGN: A single-blind randomized control trial of ASST positive patients of CU. MATERIALS AND METHODS: Patients with positive ASST were allotted into two treatment groups, named group A and group B. Patients in group A were administered azathioprine (50 mg/day) for a period of 8 weeks and followed up till 36 weeks, while patients in group B were given placebo pills. All patients were directed to take levocetirizine (5 mg) on as and when basis, in addition. Urticaria was assessed by total severity score. STATISTICAL ANALYSIS USED: MedCalc statistical software (v 12.5 for Windows) to calculate P values in independent samples by t-test, Mann-Whitney test, Friedmann test, and ANOVA. RESULTS: Administration of azathioprine in group A resulted in a significant diminution of the intensity of the disease as well as in the requirement of rescue antihistamine (positive primary and secondary outcome). CONCLUSION: Azathioprine not only had immunomodulatory properties during the treatment period, but also had lasting therapeutic effect as well. There were some gastrointestinal side effects in the initial stages but no incidence of hematological or biochemical disturbances.

Fixed drug eruptions with modafinil.

Modafinil is a psychostimulant drug, which has been approved by the US Food and Drug Administration for the treatment of narcolepsy associated excessive daytime sleepiness, sleep disorder related to shift work, and obstructive sleep apnea syndrome. However, presently it is being used as a lifestyle medicine; in India, it has been misused as an "over the counter" drug. Modafinil is known to have several cutaneous side effects. Fixed drug eruption (FDE) is a distinctive drug induced reaction pattern characterized by recurrence of eruption at the same site of the skin or mucous membrane with repeated systemic administration. Only two case reports exist in the literature describing modafinil induced FDE until date. Here, we report two similar cases. The increasing use of this class of drug amongst the medical personnel might be posing a threat to the proper use and encouraging subsequent abuse. There might be a considerable population using these drugs unaware of the possible adverse effects. Authorities should be more alert regarding the sale and distribution of such medicines.

Interstitial Lung Disease in Systemic Scleroderma, Complicated with Bilateral Pulmonary Aspergilloma: An Unusual Association.

Aspergilloma or mycetoma is a saprophytic fungal infection that colonizes pre-existing excavated lung lesion. However, its association with systemic sclerosis related interstitial lung disease is unusual and scarcely found in literature. We report a middle aged female with long standing systemic sclerosis, who was on immunosuppressive therapy for many years, presented with repeated haemoptysis. Although provisionally pulmonary tuberculosis was suspected, imaging investigations showed presence of bilateral masses inside bullous air spaces along with air-crescent sign suggestive of fungal ball. Subsequent Computed tomography guided needle aspiration from lung mass confirmed Aspergillus fumigatus as aetiologic agent on fungal culture. Patient was treated conservatively for haemoptysis and with oral antifungal drug as surgical removal of fungal ball was not an option due to poor pulmonary reserve. Although she had been treated with itraconazole for more than three years, she had recurrent haemoptysis during this period without any significant regression of size of the aspergilloma. Management of aspergilloma in a background of extensive interstitial lung disease remains poorly defined and complicated. Thereby, overall prognosis is unfavourable and depends on evolution of both underlying scleroderma as well as aspergilloma.

Primary cutaneous actinomycosis:a case report.

Actinomycosis is a subacute or chronic suppurative bacterial infection caused by filamentous gram positive, anaerobic to microaerophilic non acid fast bacilli primarily of the genus Actinomyces that normally colonize the mouth, colon and vagina. Primary cutaneous actinomycosis is a rare entity and is generally associated with trauma. We report a case of primary cutaneous actinomycosis of the back and left axilla in a 32-year-old female patient with no suggestive history of trauma.The diagnosis was suggested by the characteristic lesions with multiple discharging sinuses draining sero-sanguinous fluid scattered all over the lesions. Gram positive bacilli with plenty of pus cells were demonstrated in the direct examination of the discharging pus. Diagnosis was confirmed by isolation of the organisms by anaerobic culture giving typical molar tooth colonies. Final confirmation was done by histopathological examination.

Pseudoepitheliomatous keratotic and micaceous balanitis of Civatte.

Pseudoepitheliomatous, keratotic, and micaceous balanitis is a rare condition characterized by verrucous excrescences with scaling. Most patients are over the age of 50 and frequently have been circumcised for phimosis in adult life. We present here a case of 35-year-old male patient with long standing phimosis presenting with a firm whitish plaque on the glans penis. The crusts were micaceous in nature. Histopathologically, there was pseudoepitheliomatous hyperplasia with acanthosis and no cellular atypia. The condition was explained to the patient and treatment options discussed. The patient was started on topical 5-fluorouracil cream on a daily basis as he did not express consent for operative intervention.

Acquired universal melanosis (carbon baby syndrome).

Generalized pigmentation in a child may be attributed to a wide range of disorders. Acquired universal melanosis (AUM), also known as carbon baby syndrome, is one such rare condition, characterized by progressive hyperpigmentation of the skin since infancy with histopathologic features of heavy melanization of the entire epidermis. Since its initial description, only a few cases of AUM have been described in the English-language literature. We describe here a case of a young child with AUM for its rarity and a few unusual features.