Subcorneal Pustular Dermatosis Occuring in Association with Pyoderma Gangrenosum and Rheumatoid Arthritis: A Triple Whammy!

Neutrophilic dermatoses are a wide group of disorders encompassing indolent to severely disabling conditions. A co-existence of two such conditions, pyoderma gangrenosum (PG) and subcorneal pustular dermatosis, necessitates a thorough investigation for IgA dysglobulinemia. We report a middle-aged woman who developed PG following 18 years of (undiagnosed) subcorneal pustular dermatosis, along with rheumatoid arthritis, a known association of PG.

Triaging cases of fever with vesicular rash relevant to the monkeypox epidemic.

Fever with a vesicular rash is a common clinical scenario and monkeypox (MPX) characteristically presents as a fever with a vesiculopustular rash. The clinical morphology of MPX mimics many infectious and non-infectious disorders, and narrowing down the differentials of vesiculopustular rash necessitates thorough history taking and physical examination. The clinical evaluation involves the assessment of the primary skin lesions, sites of involvement, distribution, number and size of lesions, and pattern of progression of the rash, along with the onset of the rash relative to the occurrence of fever and other systemic signs. Common disorders which are close differentials include Varicella, Erythema Multiforme, enteroviral exanthems, and disseminated herpes simplex. Distinct clinical indicators of MPX include the presence of deep-seated umbilicated vesiculopustules, lymphadenopathy, involvement of the palms and soles, centrifugal spread, and genital involvement. We delineate and enlist features of common disorders presenting as vesiculopustular rash, which can help the clinician differentiate them from MPX.

Treatment recalcitrant cases of tinea corporis/cruris caused by T. mentagrophytes - interdigitale complex with mutations in ERG11 ERG 3, ERG4, MDR1 MFS genes & SQLE and their potential implications.

BACKGROUND: Recalcitrant dermatophyte infections are being reported from various parts of the world due to varied causes including strain variation, steroid misuse, SQLE mutations, and variable quality of itraconazole pellet formulations. The oral drug preferred in endemic areas is itraconazole, to which MIC levels remain low, and clinical failures to itraconazole reported defy a sound scientific explanation. OBJECTIVES: The objective of the study was to conduct a proteomic and genomic analysis on isolates from therapeutically recalcitrant case with isolation of gene mutations and enzymatic abnormalities to explain azole failures. METHODS: Trichophyton mentagrophyte interdigitale complex strains were isolated from seven clinically non-responding tinea corporis/cruris patients, who had failed a sequential course of 6 weeks of terbinafine 250 mg QD and itraconazole 100 mg BID. After AFST 1 strain, KA01 with high MIC to most drugs was characterized using whole genome sequencing, comparative proteomic profiling, and total sterol quantification. RESULTS: Sterol quantification showed that the standard strain of Trichophyton mentagrophytes (MTCC-7687) had half the ergosterol content than the resistant KA01 strain. Genomic analysis revealed mutations in SQLE, ERG4, ERG11, MDR1, MFS genes, and a novel ERG3 mutation. Proteomic analysis established the aberrant expression of acetyl Co-A transferase in the resistant strain and upregulation of thioredoxin reductase and peroxiredoxin. CONCLUSION: Our findings demonstrate possible reasons for multidrug resistance in the prevalent strain with mutations in genes that predict terbinafine (SQLE) and azole actions (ERG4, ERG11, ERG3) apart from efflux pumps (MDR1, MFS) that can explain multidrug clinical failures.

Current understanding of frictional dermatoses: A review.

Human skin is continually exposed to internal and external forces, dynamic as well as static. The skin is normally flexible and can resist mechanical trauma due to friction, pressure, vibration, suction and laceration to a considerable degree. However, an excess of these forces can abnormally affect the structure and function of the skin, setting the stage for the development of a skin disorder. Repetitive trauma can cause lichenification, hyperpigmentation, erythema, scaling, fissuring, blisters, ulceration and chronic alterations. Frictional dermatoses is an under-recognised entity with no clear-cut definition and encompasses a variety of terms such as frictional dermatitis, frictional melanosis, frictional pigmentary dermatoses and certain other named entities, many of which are confusing. The authors propose to define frictional dermatoses as 'a group of disorders caused by repetitive trauma to the skin as a result of friction of varied aetiology which can have a wide range of cutaneous manifestations depending on the type of insult.' The exact prevalence of frictional dermatoses as a separate entity is unknown. Authors who conducted this review include a group of dermatologists and post graduate students from various institutions. Literature was reviewed through PubMed, Medscape, Medline, ResearchGate and Google Scholar using the terms 'frictional dermatitis,' 'friction and skin,' 'dermatoses and culture,' 'clothing dermatitis,' 'friction melanosis,' 'PPE induced dermatoses in COVID-19 era,' etc. A total of 122 articles were reviewed and 100 articles among them were shortlisted and included in the study, after removing duplications. The review was followed up with further deliberation which resulted in the formulation of a new definition and classification of frictional dermatoses taking into account the morphology, histopathological characteristics, anatomical region affected and the major predisposing factors. The rising incidence of mechanical dermatoses in the COVID-19 era was also emphasised.

Case Report: Chemoradiation with Paclitaxel and Carboplatin Unveiling Leprosy Type 1 Downgrading Reaction.

Type 1 lepra reaction (T1R) is a major complication seen in nonpolar forms of leprosy and leads to significant morbidity. The classification of T1R as up and downgrading, based on previously defined histopathological criteria (by Ridley), has therapeutic and prognostic implications. The trigger factors for these reactions are poorly described, especially in case of downgrading T1R and we describe a case of leprosy reaction that was possibly triggered by chemoradiation and elucidate the possible mechanism.

Update on pharmacology, actions, dosimetry and regimens of oral glucocorticoids in dermatology.

Glucocorticoids are arguably the most widely used and misused drug in dermatology. There have been recent updates in its mode of action which can impact on its judicious use. There is need to use the correct steroid preparation to maximize results and minimize side effects. We present an updated review on glucocorticoids focusing on its mode of action, rationale of its prescribing considerations and dosing regimens in dermatology. This is based on PubMed search with a focus on mode of actions and dosimetry with additional updates from standard drug books, databases and rheumatology books.

Adjunctive use of saturated solution of potassium iodide (SSKI) with liposomal amphotericin B (L-AMB) in mucormycosis achieves favorable response, shortened dose and duration of amphotericin: A retrospective study from a COVID-19 tertiary care center.

PURPOSE: Second wave of COVID-19 pandemic was associated with an unprecedented rise in cases of mucormycosis, treatment of which has been challenging owing to the availability and side effects associated with amphotericin. METHODS: All patients presenting with rhino-orbital cerebral mucormycosis (ROCM) following COVID-19 infection between April 2021 to June 2021 were included in this retrospective interventional study. Primary objective was to assess the clinical response with combination of intravenous liposomal amphotericin B (4-5 mg/kg/day) and saturated solution of potassium iodide (SSKI) given orally along with surgical debridement. RESULTS: Twenty-five patients of ROCM were treated with the regimen. Mean age and fasting blood sugar levels were 53.48 years and 239.64 mg/dL respectively. All patients had history of intake of steroids with a mean daily dose of 86.39 mg of prednisolone equivalent. 88% of patients had a "proven" diagnosis of mucormycosis. Cultures were positive in 52% of patients with Rhizopus arrhizus as the predominant species. The mean daily dose of amphotericin received was 268 mg/day with a mean duration of 9.52 days. Mean daily dose of SSKI was 2.57 g. 21 patients (84%) had stabilization of disease at week 8 and achieved cure at the end of treatment whereas the mortality rate was 16%. Factors that significantly affected outcome were eye and central nervous system (CNS) involvement on presentation. CONCLUSION: SSKI, with its remarkably low cost and safety profile, makes it a potential adjuvant drug that may help achieve the twin benefits of shortened duration and dose of LAMB.

Role of nutritional supplements in selected dermatological disorders: A review.

BACKGROUND: While a plethora of literature continues to be published on the role of nutritional agents both in lay press and indexed journals, the data is not on a firm footing and leaves the dermatologist in a quandry and the patient confused. The various agents include vitamins, minerals, amino acids, antioxidants, diets & gluten. A proper knowledge of the role of nutritional supplements in dermatological diseases can be a useful tool in advising the patients and in certain cases ameliorating the disorder. PATIENTS/METHODS: Literature review of last 15 years was made using the terms "diet in dermatology," "nutrition and skin," "nutritional supplements in dermatology," "nutritional agents and acne," "nutritional agents and alopecia," and "nutritional agents and psoriasis." RESULTS: While there are multiple publications on the use of nutritional supplements for amelioration of skin diseases, most of them are based on either associations or in vitro studies, but very few transcend the rigors of a clinical trial or the holey grail of a double-blinded randomized controlled trial. There seem to be some evidence in acne, psoriasis, telogen effluvium, urticaria & vitiligo. Coeliac disease and dermatitis herpetiformis have a strong link with diet. Rosacea has a strong link with certain foods, but the other disorders like melasma, aphthous stomatitis do not have any scientifically validated association with diet. CONCLUSIONS: Our updated review examines the role of nutritional supplements and antioxidants in various dermatological disorders. We have found that there are varying levels of evidence with notable associations of low glycemic diet & acne, fish oil & weight loss with psoriasis, fish oils & probiotics with atopic dermatitis & vitamins & botanical extracts with vitiligo. The evidence for diet and nutrition in bullous disorders and photoageing is scarce. The role of low histamine diet in urticaria is useful in select cases of episodic urticaria. Rosacea is triggered by hot and spicy food . Apart from gluten and Dermatitis Herpetiformis, no diet can be considered disease modifying in our reveiw. The lack of comparison of nutritional or dietary modiffication with conventional validated agents, makes the data difficult to translate in real world patient management.

Does oxidative stress correlate with disease activity and severity in alopecia areata? An analytical study.

BACKGROUND: Oxidative stress (OS) has been implicated as a contributory factor in the multifactorial etiopathogenesis of alopecia areata (AA). But with the existing data, it is unclear whether OS is a cause or effect of the disease state in Alopecia areata. AIMS: To compare the OS parameters viz.malon-di-aldehyde (MDA), superoxide dismutase (SOD), total antioxidant status (TAS) in serum of patients with alopecia areata versus age and sex matched controls, and assess their correlation with the severity of the disease. PATIENTS/METHODS: Forty clinically diagnosed patients of alopecia areata and forty (n = 40) age and sex-matched healthy controls were recruited. ELISA was used for the evaluation of MDA, and spectrophotometric method was used to evaluate serum TAS and whole blood SOD. RESULTS: Mean serum TAS and whole blood SOD levels of cases were significantly lower than controls (p = 0.005 and p = 0.002, respectively). Mean serum MDA level of patients was significantly higher compared to controls (p = 0.001). While levels of serum TAS and whole blood SOD were found to decrease from mild to severe grades of disease (p = 0.003, p < 0.001 respectively), levels of MDA increased with increasing disease severity (p < 0.001). CONCLUSION: The OS parameters were deranged in all subsets of AA, with the greatest derangement seen with whole blood SOD levels.

Pseudogynecomastia: A chance occurrence with acitretin.

Psoriatic involvement of nails manifests in the form of irregular, deep and large pits, splinter hemorrhages, subungual hyperkeratosis, oil drop spot, and onycholysis of the nail bed. Retinoids are one of the treatment modalities for nail psoriasis. Pseudogynecomastia is an uncommonly reported side effect of retinoids. We hereby describe an 11-year-old adolescent who developed pseudogynecomastia posttreatment with acitretin for nail psoriasis.

A case of recurrent steroid-dependent severe type 2 lepra reaction treated successfully with colchicine.

Type 2 lepra reaction (or erythema nodosum leprosum [ENL]) is an immune complex-mediated reaction which has been reported to occur for up to 8 years after successful completion of multibacillary multidrug therapy. The management of ENL is a challenge with the patient often becoming steroid dependent; predisposing to recurrent episodes in 39%-77% of cases on attempted steroid withdrawal. Here, we present a case of recalcitrant recurrent type 2 reaction which responded promptly to treatment with colchicine.