Psychodermatology - a case for sensitization of pharmacists in Mumbai, India.

BACKGROUND: Though studies have looked at the attitudes of dermatologists towards psychodermatology, few have highlighted the attitudes of pharmacists towards these conditions. OBJECTIVES: To study the knowledge, attitudes and practices of pharmacists towards the prescription of psychotropic medications to dermatology patients. METHODS: This cross-sectional analysis included 80 pharmacists from Mumbai, India. We used an interviewer-administered questionnaire to collect information from pharmacists on their demographics, psychotropic medications in dermatological patients, knowledge about psychocutaneous conditions and comfort about dispensing these medications. RESULTS: In our study, 37 (46%) of pharmacists received prescriptions of psychotropic drugs from dermatologists; however, 24 (30%) were not comfortable dispensing them. Sixty (75%) pharmacists felt that only psychiatrists should prescribe psychotropic drugs and 37 (46%) felt that they had a right to refuse to dispense prescribed medication; of these, 15 (19%) had actually refused to give medications to patients. Pharmacists who disagreed with the statement that 'the state of mind is associated with medical conditions', were more likely to discourage psychotropic prescription from dermatologists (29% vs 11%, P = 0.04). Pharmacists with experience of more than five years were significantly more likely to refuse to dispense medications (odds ratio: 5.14, 95% confidence interval: 1.02, 25.83; P = 0.047). LIMITATIONS: We did not have a list of all pharmacists in Mumbai; thus, no sampling frame could be applied. CONCLUSION: Pharmacists do comment on doctors' prescriptions, discourage certain medications and even refuse to dispense them based on their personal opinions. Since they are the last stop for patients between the doctor and the medication, their inclusion (in addition to dermatologists, psychiatrists and psychologists) in integrated awareness, training and care programs would improve the quality of care of patients with psychocutaneous disorders.

Migratory Panniculitis with Autoimmune Cholangitis and Pancreatitis (IgG4- Related Disease): A Rare Presentation.

A 30-year-old woman presented with an acute-onset high-grade fever (103°F), multiple episodes of throbbing abdominal pain in the right quadrant, and pustular red lesions on the left leg. The radiological findings were suggestive of autoimmune cholangitis and pancreatitis. The skin lesions recurred on different portions of the body, and histopathological findings showed lobular and septal lymphohistiocytic infiltrate without vasculitis. The epidermis had focal ulcerations, and the dermis showed the presence of subcutaneous fat and an infiltrate of lymphocytes, histiocytes, and neutrophils (described as lobular and septal panniculitis without vasculitis). Based on the clinical and histopathological features, a diagnosis of migratory panniculitis was made. The patient was managed with analgesics, antibiotics, and a long course of steroids; the patient responded well to these medications. To the best of our knowledge, this is one of the first case reports of migratory panniculitis associated with IgG4-related disease. Patients with migratory panniculitis should be investigated for the presence of IgG4-related autoimmune disease. However, steroids remain the drug of choice when these conditions occur together.

Hair Styling Procedures and Hair Morphology: A Clinico-Microscopic Comparison Study.

BACKGROUND: The present study is a cross-sectional comparison to evaluate the association between hair loss and hair structural changes (gross and microscopic), and hairstyling procedures in women. METHODS: We included 94 women; and collected data on sociodemographics, clinical history, sun-exposure, and hair-product use history. Women who reported blow drying of hair, hair straightening, use of hair iron or perming in the past 6 months were classified as cases. Age matched (±2 years) women who did not report any of the above procedures in the past 6 months were controls. The following tests were done: hair pull test; hair density assessment; hair breakage index (HBI); and microscopic examination. A logistic regression model was used for estimation of the odds ratio (OR) and 95% confidence intervals (CI). RESULTS: The mean (standard deviation [SD]) age in the case and control group was 26.4 (6.3) and 27.4 (6.3) years, respectively (P = 0.43). There was no significant difference in the mean (SD) HBI (1.05 [0.08] vs 1.07 [0.05], P = 0.22) or hair density (3.28 [0.41] vs 3.16 [0.39], P = 0.19). Cases were significantly more likely to have microscopic changes compared with controls (OR: 22.0, 95% CI: 4.3, 112.6; P < 0.001). Sun exposure for more than 3 h was significantly associated with microscopic changes (OR: 6.7, 95% CI: 1.2, 39.1; P = 0.03). CONCLUSION: Women with hairstyling procedures in the past 6 months were more likely to have microscopic changes, even though there was no difference in the hair assessment parameters. Specific guidelines on use of hairstyling procedures for Indian hair should be developed.

A Study of Risk Factors of Chronic Venous Insufficiency and its Association with Features Suggestive of Preceding or Present Deep Venous Thrombosis.

BACKGROUND: Deep venous thrombosis (DVT), even though resolved, may damage the valves and may lead to chronic venous insufficiency (CVI). We designed the present study to examine the thrombotic markers or other ultrasound features in the absence of active thrombosis in patients presenting with features suggestive of CVI. MATERIALS AND METHODS: It was a cross-sectional study of 50 DVT patients. We collected a detailed history of presenting symptoms (onset, progression, and duration) and associated history of aggravating factors. After classifying the patients, color Doppler investigation for DVT and venous incompetence and blood investigations such as Factor V, D-Dimer, total cholesterol, total triglycerides, homocysteine, high-density lipoproteins, low-density lipoproteins (LDL), and very LDL were done. RESULTS: We found a raised Factor V significantly more in patients classified as severe under clinical classification compared with nonsevere (19% and 0%; P = 0.05) and in patients with a high Venous Severity Clinical Score (VSCS) compared to those with a low VSCS score (17% and 0%; P = 0.03). We also found that perforators were significantly more in patients with a high VSCS score (88% and 58%; P = 0.02), in patients with a primary venous etiology compared with those without any venous etiology (97% and 1%; P < 0.0001), in patients with obstruction/reflux compared to those without any pathology (95% and 0%; P < 0.0001), and in patients with severe clinical classification compared with nonsevere patient (95% and 55%; P = 0.002). CONCLUSIONS: Clinical or subclinical DVT, an important cause of CVI, may not always be seen on ultrasound, especially after resolution. However, they may have the presence of blood parameters (Factor V and hyperhomocysteinemia) suggestive of DVT; these can be used as proxy markers for the current or previous DVT.

Acquired zinc deficiency in a renal transplant recipient with gastrointestinal tuberculosis responding promptly to oral correction.

Zinc deficiency is an uncommon condition, known to occur in two forms: inherited type, known as Acrodermatitis enteropathies and the acquired type. Cutaneous clinical manifestations observed include characteristic dermatitis on acral, periorificial, and anogenital areas through an unknown mechanism. The patient had a combination of causes which lead to a state of zinc deficiency. We are presenting it due to the rarity of acquired acrodermatitis in patients of gastrointestinal tuberculosis and renal transplant recipients. We emphasize the awareness about this condition, especially in resource-poor settings, where serum zinc levels may not be available, and a trial of oral zinc may be given.

Mononucleosis-like drug rash: an interesting case presentation.

Dapsone hypersensitivity syndrome (DHS) is a rare adverse effect of the commonly prescribed drug dapsone. We present a case of a 35-year-old male who was referred to us from the gastroenterologist with complaints of rash, nausea, vomiting, and jaundice since 2 days with a provisional differential diagnosis of infectious mononucleosis or viral exanthema. On enquiry patient gave history of taking dapsone a week prior for refractory urticaria. After thorough investigations we diagnosed him with DHS. This syndrome occurs in a relatively small proportion of patients, but it is associated with considerable morbidity and mortality. The reason for presenting this case is to remind physicians of the unpredictability and potential severity of this reaction which makes it a major concern in clinical practice.

Recalcitrant pruritus as primary manifestation of synchronous Hodgkins lymphoma and Langerhans cell histiocytosis.

We present a 73 year old female with intractable pruritus and nonspecific cutaneous rash for a period of 9 months. She had recieved symptomatic therapy with no improvement. A complete examination revealed axillary and abdominal lymphadenopathy. A biopsy confirmed the diagnosis of Hodgkins lymphoma with Langerhans cell histiocytosis. She received 5 cycles of chemotherapy with resolution of pruritus and reduction in axillary and abdominal lymphadenopathy. The patient presented 6 months later with relapse and succumbed to the illness. Simultaneous occurrence of Langerhans cell histiocytosis and Hodgkins lymphoma may lead to misdiagnosis. The awareness of such an association is important to make an accurate diagnosis and guide appropriate therapy.

Reversal of nail changes after liver transplantation in a child.

We report a 6-year-old girl who received a left-lobe live-related liver transplant for decompensated liver disease after a failed Kasai's surgery for biliary atresia. Preoperatively, her nails were white, dystrophic, brittle with severe onycholysis, clubbing and watch-glass deformities. Nail scrapings were negative for fungus. Five months after transplantation, her nails had become near normal. There is only one such documented case in literature on reversal of nail changes in an adult.