Prospective evaluation of psychological burden in patients with oral cancer.

The high morbidity and mortality that is associated with oral cancer places a huge psychological burden on patients. The purpose of this prospective study was to evaluate levels of depression, anxiety, and stress, at three time points using DASS-21 (Depression, Anxiety and Stress Scale-21). We also compared DASS-21 with HADS (Hospital Anxiety and Depression Scale). A total of 111 patients were enrolled and 75 of them completed the questionnaires at diagnosis, one month after treatment, and three months after discharge. Scores were high for stress at diagnosis, and for depression at the other time points, but were low for anxiety at all three. The results of Friedman's ANOVA showed that mean ranks for depression and stress were significant (p<0.05). Scores for depression and stress rose significantly between diagnosis and three months after operation, but those for anxiety (which had increased between diagnosis and operation p>0.05), were stable three months postoperatively. The DASS-21 was a useful method of evaluating stress. Correlation of the results from the two questionnaires showed a strongly positive association. We therefore recommend psychological intervention to improve overall outcome.

Drug-induced photosensitivity: new insights into pathomechanisms and clinical variation through basic and applied science.

Drug-induced photosensitivity occurs when a drug is capable of absorbing radiation from the sun (usually ultraviolet A) leading to chemical reactions that cause cellular damage (phototoxicity) or, more rarely, form photoallergens (photoallergy). The manifestation varies considerably in presentation and severity from mild pain to severe blistering. Despite screening strategies and guidelines in place to predict photoreactive drugs during development there are still new drugs coming onto the market that cause photosensitivity. Thus, there is a continuing need for dermatologists to be aware of the different forms of presentation and the culprit drugs. Management usually involves photoprotection and cessation of drug treatment. However, there are always cases where the culprit drug is indispensable. The reason why some patients are susceptible while others remain asymptomatic is not known. A potential mechanism for the phototoxic reactions is the generation of reactive oxygen species (ROS), and there are a number of reasons why some patients might be less able to cope with enhanced levels of ROS.

Evaluation of cyclophosphamide pulse therapy as an adjuvant to oral corticosteroid in the management of pemphigus vulgaris.

Corticosteroids are the mainstay of treatment for pemphigus. However, despite the introduction of adjuvant therapy for PV, the mortality rate has remained static over the past 2 decades, and consequently, a new adjuvant therapy that is both safe and effective is needed. Intravenous pulse cyclophosphamide has shown encouraging results in few studies, with a better safety profile than the oral formulation, and with better treatment compliance. We undertook a randomized, prospective, non-blinded trial to assess the efficacy of cyclophosphamide pulse therapy (CPT) as an adjuvant to oral corticosteroid in pemphigus vulgaris (PV). We enrolled 60 patients with mild to moderate active disease to receive either daily oral prednisolone or intravenous CPT prednisolone for 1 year, and they were then followed up for another year. At the end of the study period, the time taken to initiate response was similar in both groups, but in the group who received pulse cyclophosphamide, there was a reduced time to remission, a greater proportion of cases who achieved remission, a lower number of patients who relapsed while on treatment or after stopping treatment, and a lower cumulative dose of corticosteroid. Hence, the overall trend was in favour of CPT, although this was not significant. CPT also had a good safety profile. Based on the results of this trial, CPT may be a useful adjuvant in PV in terms of reducing time to remission, relapse rates and cumulative dose of steroid, and it has a good safety profile.

Comparison of efficacy and side-effect profile of oral PUVA vs. oral PUVA sol in the treatment of vitiligo: a 36-week prospective study.

BACKGROUND: Both Oral PUVA and PUVA sol have been successfully used in vitiligo treatment. However, there is paucity of studies comparing the two therapies, especially under subtropical conditions of abundant sunlight where PUVA sol is more feasible. OBJECTIVES: To compare the efficacy and side effects of oral PUVA versus oral PUVA sol therapy in generalized vitiligo. METHODS: Comparative prospective clinical trial conducted on consecutive patients of generalized vitiligo. Response to treatment was assessed using change in Lund & Browder (L & B) score for assessment of reduction in body surface area of involvement, patient global assessment (PGA) of improvement in vitiligo, investigator's global assessment (IGA) of extent of repigmentation, and quality of life (QOL) assessment using Tjioe et al questionnaire. RESULTS: Thirty five patients were recruited- 18 in PUVA and 17 in PUVA sol group. Mean percentage change in L & B score at 36 weeks was 46.4% in PUVA and 26.1% in PUVA sol group (P = 0.06), mean PGA score in PUVA was 4.58 ± 2.23 and in PUVA sol group was 6 ± 2.08 (P = 0.13), mean IGA score was 3.08 ± 1.68 in PUVA and 1.79 ± 0.57 in PUVA sol group (P = 0.11). QOL scores were significantly higher in PUVA group as compared to the PUVA sol group (P = 0.04). Side effects were comparable in two groups except for phototoxic side effects which were significantly more in PUVA group. CONCLUSIONS: PUVA is more efficacious than PUVA sol and also provides greater psychological benefit in treatment of generalized vitiligo but is associated with more phototoxic adverse effects.

Utility of desmoglein ELISA in the clinical correlation and disease monitoring of pemphigus vulgaris.

BACKGROUND: Pemphigus vulgaris (PV) is a relatively common autoimmune blistering disease in India. Recently, enzyme-linked immunosorbent assay (ELISA) test against desmoglein1 (Dsg 1) and desmoglein3 (Dsg 3) has been developed, which is found to be highly sensitive and specific. OBJECTIVE: To assess the utility of ELISA for monitoring the disease of PV. METHODS: Serum samples from 63 active PV patients were tested for anti-Dsg1 and anti-Dsg3 using ELISA. They were tested for anti-Dsg1 and anti-Dsg3 reactivity before treatment. The test was performed during remission period and after relapse using commercially available ELISA kit. RESULTS: Both anti-Dsg1 and anti-Dsg3 levels were found to be raised in PV patients. Thirty-eight patients went on remission during treatment phase with mean anti-Dsg1 and anti-Dsg3 values, 13.18 U/mL and 18.89 U/mL respectively. Difference of baseline from remission was found to be significant (P < 0.001). Of these, 23 patients relapsed either during treatment phase or after stoppage of therapy and their mean anti-Dsg1 and anti-Dsg3 titres were 39.49 U/mL and 96.99 U/mL respectively. Difference of remission from relapse was also found to be significant (P < 0.001). The 50 U/mL cut-off for anti-Dsg1 ELISA provided 73.91% sensitivity and 72.5% specificity respectively. The 98.57 U/mL cut-off for anti-Dsg3 provided 82.61% sensitivity and 82.5% specificity respectively. CONCLUSION: ELISA is less time consuming, less expensive and a potential diagnostic test for PV. It is also highly sensitive and specific test for Indian patients in whom the mean anti-Dsg titres are raised.

Comparison of clobetasol propionate cream plus coal tar vs. topical psoralen and solar ultraviolet A therapy in palmoplantar psoriasis.

AIM: Palmoplantar psoriasis (PPP) produces significant morbidity and requires prompt treatment. Topical agents form the mainstay of therapy. We compared the efficacy and side-effect profile of a steroid/coal-tar combination with topical psoralen and solar ultraviolet A (PUVAsol) in PPP. METHODS: In total, 52 patients with PPP were randomized to receive either a combination of clobetasol propionate cream and coal tar daily (group 1) or topical PUVAsol on alternate days (group 2) for 16 weeks. Response was assessed as change in Psoriasis Activity and Severity Index (PASI) and Patient Global Assessment (PGA). RESULTS: Of the 52 patients, 43 completed the treatment phase. There was a reduction in PASI for the palms and soles in both treatment groups throughout the treatment period until week 16. There was a greater reduction in PASI in palmar psoriasis with topical PUVAsol, and a greater reduction in psoriasis of the soles with the steroid/coal-tar combination. In both groups, patients perceived 'good improvement'. Improvement or cure in palmar lesions was observed in 90% of cases in the topical steroid/coal-tar group and in 75% of cases in the topical PUVAsol group; for the soles, these figures were 76% and 79%, respectively. No adverse effects were experienced with the steroid/coal-tar combination, whereas for the topical PUVAsol, phototoxicity occurred in 22% of cases. CONCLUSION: Both treatments had comparable efficacy. In both groups, patients experienced 'good improvement' after 16 weeks of therapy.

Clinical and bacteriological profile and outcome of sepsis in dermatology ward in tertiary care center in New Delhi.

BACKGROUND: There is paucity of data regarding the clinical and bacteriological profile of sepsis in dermatology in-patients. AIMS: To study the frequency, etiology, and outcome of sepsis dermatology in-patients. METHODS: The study was conducted in a 30-bedded dermatology ward of a tertiary care center. Sepsis was defined by presence of ≥2 SIRS (systemic inflammatory response syndrome) criteria along with evidence of infection (clinically obvious/culture proven infection of skin or internal organs). Patients were also assessed for known (common) risk factors of sepsis. In suspected sepsis patients, at least two samples of blood cultures by venepuncture were taken. Pus, skin swab, urine, and sputum samples were also collected for culture as needed with avoidance of contamination. RESULTS: Among 860 admitted patients studied from November 2004 to July 2006, 103 (12%) fulfilled SIRS criteria. Of these, 63 had nonsepsis causes of SIRS positivity, while 40 (4.65%) had sepsis. Majority of the sepsis patient had vesicobullous diseases (42.5%), erythroderma (25%), toxic epidermal necrolysis (TEN) (22.5%). Severe sepsis developed in 17 (42.5%) patients, while 15 (37.5%) died. Methicillin-resistant Staphylococcus aureus (MRSA) was the commonest organism isolated (99; 25.9%) in all culture specimens followed by Acinetobacter spp. (52; 13.6%), Pseudomonas spp. (40; 10.5%), Methicillin-sensitive S. aureus (MSSA: 33; 8.7%), and Klebsiella spp. (22; 5.8%). Various risk factors affecting mortality and sensitivity patterns for various isolates were also analyzed. CONCLUSION: Sepsis occurred in 40 (4.65%) inpatients in dermatology ward. The frequency of sepsis was highest in TEN (90%), followed by drug-induced maculopapular rash (20.0%), erythroderma (17.5%), and vesicobullous diseases (8.5%). MRSA, acinetobacter, pseudomonas, MSSA, and Klebsiella were important etiological agents involved in sepsis in dermatology in-patients.

Ocular morbidity in leprosy patients with lagophthalmos.

Lagophthalmos is a well known complication in leprosy due to the involvement of seventh cranial nerve resulting in incomplete closure of the eyelids. The real magnitude of ocular morbidity as a consequence of lagophthalmos is unknown, as several ocular complications can occur independently due to involvement of the fifth (trigeminal) nerve or due to secondary infection. Therefore, a study was designed to carefully examine the eyes of 100 consecutive leprosy patients with lagophthalmos seeking treatment at a leprosy referral centre in Delhi. Among the eyes examined, 145 had lagophthalmos. The symptomatology and anterior-posterior chamber morbidity in eyes with lagophthalmos were significantly higher as compared to unaffected eyes. Significantly, higher morbidity was seen regardless of sex or type of leprosy or deformity. Capacity building of the health professionals regarding ocular morbidity and increased emphasis on the importance of self care among patients can significantly reduce ocular morbidity.

Dapsone-induced eosinophilic pneumonitis in a leprosy patient.

A leprosy patient with no prior history of respiratory complaints, developed symptoms of dry cough, fever and dyspnea after six weeks of therapy. Peripheral eosinophilia and radiological evidence of pulmonary interstitial infiltrates pointed towards the possibility of drug-induced eosinophilic pneumonitis. The results of relevant tests for other possible pathologies were normal. The resolution of symptoms without any intervention other than withdrawal of the drug and subsequent re-challenge proved dapsone to be the cause.

Ichthyosis follicularis, alopecia and photophobia (IFAP) syndrome treated with acitretin.

We describe a 3-year-old male patient with the ichthyosis follicularis, alopecia and photophobia (IFAP) syndrome, who developed cutaneous and ocular involvement in infancy. In addition, he had growth retardation and borderline intelligence; no other systemic involvement was found on detailed investigation. A moderate response to acitretin therapy (1 mg/kg) administered for 6 months was observed, with improvement in cutaneous features and corneal erosions and no change in alopecia or photophobia.

A randomized placebo-controlled double-blind study of levamisole in the treatment of limited and slowly spreading vitiligo.

BACKGROUND: A previous uncontrolled, open trial of levamisole in patients with limited and slowly spreading vitiligo had shown that new lesions did not develop in 94% of patients after 2-4 months of treatment with the drug. OBJECTIVES: To assess the efficacy of levamisole in the treatment of slowly spreading, limited vitiligo. METHODS: In a randomized double-blind trial at the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India, 60 patients with vitiligo involving < 2% of the body surface area and with slowly spreading disease (defined as one to five new lesions in the previous month or six to 15 new lesions in the previous 3 months) were randomly allocated to receive oral levamisole 150 mg or placebo on two consecutive days in a week. Children received oral levamisole 100 mg. All patients applied mometasone furoate 0.1% cream on the depigmented macules once daily. Patients were evaluated monthly for 6 months. The main outcome measure was the occurrence of new lesions, counted at each monthly visit. The secondary outcome measures comprised: (i) a dermatology-specific instrument, the Dermatology Life Quality Index or Children's Dermatology Life Quality Index questionnaires, which were completed by the patients at baseline and at every visit, and (ii) a general health questionnaire, the World Health Organization Quality of Life Brief Questionnaire, which was completed at baseline and at the end of the study. RESULTS: Forty-three patients completed 6 months of follow-up. The mean +/- SD number of new lesions that developed during the study period of 6 months was 1.9 +/- 2.0 (range 0-8) in the levamisole group and 1.8 +/- 2.0 (range 0-7) in the placebo group (P = 0.92). The proportion of patients who did not develop any further new lesions for the remainder of the study period was higher in the levamisole group at all the monthly evaluation points, although it was statistically significant (P = 0.05) only at the fourth month. Improvement in quality of life was similar in both groups. CONCLUSIONS: The study indicates that levamisole is not as effective in arresting disease progression as was observed in a previous open study. A study with a larger sample size is necessary to determine if levamisole is truly superior to placebo in this respect.

Topical immunomodulators in dermatology.

Topical immunomodulators are agents that regulate the local immune response of the skin. They are now emerging as the therapy of choice for several immune-mediated dermatoses such as atopic dermatitis, contact allergic dermatitis, alopecia areata, psoriasis, vitiligo, connective tissue disorders such as morphea and lupus erythematosus, disorders of keratinization and several benign and malignant skin tumours, because of their comparable efficacy, ease of application and greater safety than their systemic counterparts. They can be used on a domiciliary basis for longer periods without aggressive monitoring. In this article, we have discussed the mechanism of action, common indications and side-effects of the commonly used topical immunomodulators, excluding topical steroids. Moreover, newer agents, which are still in the experimental stages, have also been described. A MEDLINE search was undertaken using the key words "topical immunomodulators, dermatology" and related articles were also searched. In addition, a manual search for many Indian articles, which are not indexed, was also carried out. Wherever possible, the full article was reviewed. If the full article could not be traced, the abstract was used.

Giant combined dermatofibroma with satellitosis.

An unusual giant combined dermatofibroma is reported in a 34-year-old man who presented with skin-coloured swellings on the medial aspect of the left scapula. The plaque was well defined, reddish-brown and 25-30 cm in diameter. It was also tender and indurated. Several similar smaller lesions (satellites) were present around the plaque. Light microscopy of an incisional biopsy from the main lesion showed architectural features of a deep penetrating type of dermatofibroma, with xanthomatous aggregates, myxoid changes and probable myofibroblastic differentiation. Our case represents an extraordinary example of giant combined dermatofibroma with satellitosis. Despite its benign nature, a wide excision is contemplated because of its unsightly appearance and physical discomfort.

Neurofibromatosis I with unusual hypopigmentation masquerading as leprosy.

A case of Neurofibromatosis I (NFI) occurring in association with symmetrical peripheral nerve enlargement and multiple hypopigmented macules strikingly limited to the neurofibromas, with normal to minimally reduced sensations, evoking a strong clinical suspicion of co-existent lepromatous leprosy, is being reported. Leprosy was ruled out by microbiological, histopathological and electrophysiological studies. The case is interesting in view of the hypopigmented macules overlying the neurofibromas, which is an unreported feature of NFI.

Lupus vulgaris: unusual presentations over the face.

Lupus vulgaris (LV) is the most common morphological variant of cutaneous tuberculosis. However, the occurrence of bizarre clinical presentations over atypical sites often leads to misdiagnosis and inappropriate treatment causing significant morbidity. This report seeks to highlight two unusual cases of lupus vulgaris occurring on the face of immunocompetent women and remarkably mimicking periorbital cellulitis and basal cell carcinoma, respectively. The diagnosis was confirmed by histopathology, an enzyme-linked immunosorbent assay (ELISA) test for Mycobacterium tuberculosis and polymerase chain reaction (PCR). With four-drug antitubercular therapy, both patients had a dramatic response.