A prospective comparative study of efficacy and safety of 15% trichloroacetic acid peel, 35% glycolic acid peel and Q-switched Nd-YAG laser in patients of macular amyloidosis.

Background: The unappealing appearance of skin in macular amyloidosis (MA) interferes with the patient's quality of life, and treating the condition has been challenging. Aims and Objectives: To compare the efficacy and safety of 15% trichloroacetic acid (TCA) peel, 35% glycolic acid (GA) peel, and Q-switched Nd-YAG Laser in MA. Materials and Methods: Open, prospective study was conducted over 2 years, where after fulfilling the criteria, randomization was done into three groups. Group A: 15% TCA peel; Group B: 35% GA peel; Group C: Q-switched Nd-YAG Laser. Procedures were repeated at monthly intervals for six sittings. On each visit, patients were scored on the following parameters: color score, visual analog score (VAS), physician global assessment (PGA) scale, subjective improvement, and adverse effects. Results: A total of 75 patients (25 patients in each group) completed the treatment. The mean age of study-population was 35.68 ± 9.8 years, with female to male ratio of 11.5:1. The mean change in color score (1.68) was more by Group A, followed by Group C (1.4), followed by Group B (1.16). Similar results were noted by subjective improvement, VAS, and PGA. Adverse events were more in Group A, followed by Group C, followed by Group B. No patient showed permanent adverse events. Conclusion: TCA-peel showed superior results over Nd-YAG laser and glycolic-acid peel. TCA-peel being cost-effective with excellent acceptability should be considered a treatment modality.

Syphilis: Is it Back with a Bang?

Background: Syphilis was brought under control with the advent of penicillin. However, in recent times, a rise in the incidence of syphilis has been reported by Centers for Disease Control and Prevention (CDC). Aim: To study the clinical and epidemiological profile of patients with syphilis attending sexually transmitted infection (STI) clinic at tertiary care center. Materials and Methods: Observational, cross-sectional analysis of sociodemographic, clinical, and investigational data of all syphilis patients visiting STI clinic from August 2019 to July 2021 was done and analyzed. Results: Out of 1330 STI patients that attended the clinic, 15.04% (n = 200) were diagnosed with syphilis, among them 72% (n = 144) were males, and 28% (n = 56) were females, with male-to-female ratio of 2.5:1. Of these 24.5% (n = 49) had primary, 44.5% (n = 89) had secondary, 30.5% (n = 61) had latent, and 0.50% (n = 1) had congenital syphilis. Among secondary syphilis patients, rash was the most common presentation seen in 43 patients, followed by condyloma lata in 30, palmoplantar syphilis in 17, oral mucous patch in 3, and iridocyclitis in 3 patients. Human immunodeficiency virus (HIV) was positive in 16.5% (n = 33). Herpes genitalis was the most common coinfection among 25 patients who were diagnosed with mixed venereal disease. RPR titer was positive in all 200 patients, with 1:16 titer being most common. Conclusion: India is experiencing a new trend in the prevalence of syphilis, mainly due to the changes in risk behavior, misconceptions, and social stigma associated with STIs, improved laboratory diagnosis, and increased public awareness. Particularly secondary and latent stages have shown a rising trend over the past few years. Awareness about safe sexual practices and contraception is very important to control the current resurgence.

A Comparative Study on Therapeutic Efficacy of Autologous Platelet-rich Plasma, Autologous Platelet-rich Fibrin Matrix, Recombinant Human Epidermal Growth Factor, and Collagen Particles in Nonhealing Leg Ulcers.

Background: Nonhealing leg ulcers are challenging to manage and cause significant patient morbidity. To promote healing, newer techniques focus on delivering/enhancing dermal matrix components. Aim: The aim of this study was to compare the therapeutic efficacy of autologous platelet-rich plasma (PRP), autologous platelet-rich fibrin matrix (PRFM), recombinant human epidermal growth factor (rhEGF), and collagen particles in treating nonhealing leg ulcers. Materials and Methods: Open, randomized prospective study was conducted in a single tertiary center over 2 years where after fulfilling the criteria, randomization was done into four groups. Group A: Autologous PRP (double spin, manual method, weekly); Group B: Autologous PRFM (weekly); Group C: rhEGF (daily application); and Group D: Collagen particles (weekly) along with cleansing, debris removal, and wound dressing. Treatment endpoints were complete healing/6 months of treatment, whichever was earlier. Follow-up was done two weekly by clinical assessment, photographs, and measurement of the ulcer area. Epi info 7 software was used for statistical analysis. Results: A total of 48 patients completed the study, 12 in each group, with mean age: 42.37 ± 4.56 years and male-to-female ratio 2.6:1. Underlying etiology was varicosities (43.75%), traumatic (25%), diabetes (22.91%), and leprosy (8.34%). At baseline, all groups were comparable in terms of patient and ulcer characteristics. Complete healing was seen in 79.17% at the end of 12 weeks: 91.67% of patients from Groups A and B each, and 66.67% from Groups C and D each. The mean time to complete healing was 6.9 ± 2.5 weeks, the least in Group B (4.73 ± 2.3 weeks). Differences between excellent (≥75%) ulcer healing across all groups were statistically significant at the end of 8 weeks where Group B showed maximum improvement. No major adverse events were seen. Conclusion: PRFM resulted in relatively faster ulcer healing compared with other modalities.

A single-centre prospective study comparing efficacy and safety of apremilast with cyclosporine in moderate to severe atopic dermatitis.

BACKGROUND: Apremilast regulates several pro-inflammatory signals involved in atopic dermatitis (AD). METHODS: A randomized, open-labelled study was conducted at a tertiary care centre in India. Fifty patients with AD of >1 year duration were randomly assigned in a 1:1 ratio to receive either apremilast (30 mg twice daily after initial titration) or cyclosporine (5 mg/kg/day) for 24 weeks, followed by a 12-week follow-up period. Primary outcome was mean percentage change in Eczema Area and Severity Index (EASI) from baseline to week 24. Secondary outcome measures were proportion of patients achieving EASI 75, EASI 90, ≥2-point improvement in Investigator's Global Assessment (IGA), SCORing Atopic Dermatitis (SCORAD) 75 at week 24 and percentage of patients experiencing ≥1 adverse effect (AEs). RESULTS: Mean percentage change in EASI (standard deviation) was -67.79% [22.44] in the apremilast treatment group and -83.06% [21.20] in the cyclosporine treatment group (p < 0.05). At week 24, 52.38% of patients in the apremilast group and 78.26% in the cyclosporine group achieved EASI 75 (p < 0.05); 14.29% in the apremilast group and 52.17% in the cyclosporine group achieved EASI 90 (p < 0.05) and 80.95% in the apremilast group and 82.60% patients achieved ≥2 point reduction in IGA (p > 0.05). 57.14% of patients achieved SCORAD 75 in the apremilast group and 69.56% in the cyclosporine group (p > 0.05). Mean time taken to achieve EASI 75 in the apremilast group was 4.50 ± 4.62 weeks, while it was 3.96 ± 3.43 weeks in the cyclosporine group (p > 0.05). Incidence of AEs was 28.57% in the apremilast group and 21.74%) in the cyclosporine group. CONCLUSIONS: Apremilast demonstrated lesser efficacy in comparison to cyclosporine; it has the advantage of a favourable safety profile and requires no laboratory monitoring.

A Clinical-Mycological Study of Dermatophytosis in Western India with Focus on Antifungal Drug Resistance as a Factor in Recalcitrance.

Background: Dermatophytosis have assumed epidemic proportions in India. Antifungal drug resistance solely cannot explain disease magnitude and changing epidemiology. Objectives: Aim of this study was to analyse clinical-mycological aspects of dermatophytosis, and estimate contribution of drug resistance in clinical recalcitrance. Methods: This single-centre observational, cross-sectional, descriptive study was done in tertiary centre of western India after ethical approval, enrolling dermatophytosis patients of all ages and sex. After history and examination, KOH mount and culture in modified SDA medium was done. Culture positive isolates were subjected to E-strip antifungal susceptibility method to test MIC for Terbinafine, Itraconazole, Fluconazole and Griseofulvin. Results: Total 300 patients were included, with mean age of 33.83±27.5 years and male-to-female ratio of 1.22:1; tinea corporis et cruris being commonest, 39.33% (n=118). Only 11.67% (n=35) were treatment naïve, having classical annular morphology. History of topical steroid abuse was found in 81.67% (n=245), with pseudoimbricate lesions in 70.61% (n=173). 86.67% (n=260) had KOH positivity while 83.33% (n=250) had culture positivity: Trichophyton mentagrophytes 45.6% (n=114), followed by Trichophyton rubrum in 34.4% (n=86). A total of 265 patients fit into definition of recalcitrance, from which 12.45%, i.e., 33 isolates showed in-vitro fluconazole resistance. 14.33% (n=43) cases were chronic, 37% (n=111) persistent, 46% (n=138) recurrent while 17% (n=51) had relapse in their disease course. Steroid abuse was the commonest denominator. Conclusion: Role of antifungal resistance in recalcitrant dermatophytosis remains debatable. Stopping steroid abuse, which is often the commonest culprit, with adherence to standard antifungal therapy remains the paradigm in management.

A Rare Case of Congenital Herpes Simplex Virus Infection with Therapeutic Response to Acyclovir.

A 1-day-old pre-term female child delivered by lower segment cesarean section was referred for hypo-pigmented skin lesions over trunk since birth. After 3 days, the neonate developed vesicles and pustules. The mother gave a history of fluid-filled genital lesions at the 12th week of gestation. The diagnosis of neonatal herpes infection was suspected clinically, which was confirmed by polymerase chain reaction, and the lesions resolved following injectable acyclovir.

The Enigma of Periorificial Desquamating Lesions in a Child.

Biotinidase deficiency (BD) is a rare autosomal recessive, vitamin-responsive inborn error of metabolism associated with a wide spectrum of dermatological, neurological, auditory, and metabolic abnormalities. This case report reiterates that a high index of suspicion in childhood diseases with periorificial desquamation can lead to timely detection and active intervention in BD.

Presentation of Hansen's disease as Lucio phenomenon in an Indian male.

Lucio phenomenon is a reactional state described in patients with Lucio leprosy and in a few cases of lepromatous leprosy; it is rarely seen outside Mexico and Central America. We report a case of 35-year old labourer who presented with clinical features classical of Lucio phenomenon without any pre-existing cutaneous nodules or infiltrative lesions of either Lucio or lepromatous leprosy. This case report demonstrates the need to consider Lucio phenomenon in patients presenting with clinical features of medium vessel vasculitis even in areas not endemic for Lucio leprosy.

Clinical, Laboratory, Histopathological and Therapeutic Profile of Livedoid Vasculopathy: A Case Series of 17 Patients.

Livedoid vasculopathy is a rare disorder clinically presenting with triad of livedo reticularis, leg ulcerations, and atrophie blanche. We present a case series of 17 patients with clinical and/or histopathologically confirmed livedoid vasculopathy from a single tertiary centre in India with female-to-male ratio of 1.5:1 and mean age of 36.12 ± 12.02 years. Presentation with burning pain around ankles was seen in 83.33% of patients, while 100% had atrophie blanche/scarring and 76.47% had retiform ulcers. Hypercholesterolemia was seen in four patients, while systemic lupus erythematosus (SLE), anti-phospholipid antibody with SLE, dermatomyositis and hyper-homocysteinemia were seen in one patient each. The most common histopathology finding was hyaline thrombi within dermal vessels in 94.11%. On treatment with dual anti-platelet therapy, 70.58% of patients could achieve significant improvement in their Visual Analog Scale, Dermatology Life Quality Index and reduction in ulcer scores without serious adverse events. Out of 17 patients, 11 experienced flare in their disease course over one year period of follow-up. This cohort aims to contribute to Indian literature of this underreported entity.

Long-term efficacy and safety analysis of single cycle of biosimilar rituximab in pemphigus: A retrospective study of 76 patients from India.

Pemphigus poses a therapeutic challenge and rituximab is increasingly used in its treatment. Long-term data regarding efficacy and safety of rituximab in pemphigus is limited. This study was a retrospective analysis of 76 pemphigus patients with primary endpoint being the percentage of patients achieving complete remission (CR) on/off therapy. Secondary endpoints were time to relapse, mean cumulative dose of prednisolone after rituximab infusion, mean duration of follow up, and adverse events to rituximab if any. A total of 62 (82.7%) attained complete remission on/off treatment, out of which 42 were off therapy. Mean interval between rituximab administration and complete remission off treatment was 6.9 ± 3.7 months. Complete remission off treatment was sustained for a mean duration of 21.4 ± 17.8 months before relapse. Over a mean follow-up duration of 42.7 ± 24.9 months (median 41, maximum 83 months), 22 of 62 patients (35.5%) who had achieved complete remission after the first cycle of rituximab relapsed. A mean total cumulative dose of 8716.3 ± 10533.8 mg prednisolone was prescribed over a mean duration of 18.05 ± 15.64 months after the first cycle of rituximab. Adverse events were noted in 18 out of 76 patients (23.7%) which included infusion reactions (n = 3), minor infections (n = 7), transitory disease flare (n = 6), and mortality (n = 2). No statistically significant correlation was found between remission/relapse rates and age, gender or pemphigus subtype. This study substantiates the long-term efficacy and safety of single cycle of rituximab in pemphigus.

Real-world Efficacy and Safety of Apremilast Monotherapy in the Management of Moderate-to-severe Psoriasis.

INTRODUCTION: Apremilast is the new oral drug in the management of moderate-to-severe plaque psoriasis with well-established effectiveness and safety in long-term clinical trials and a few real-world studies. However, its effectiveness and safety in Indian setup have not been reported yet. MATERIALS AND METHODS: This was retrospective, single-center, longitudinal, observational cohort study where the total study period was 24 weeks. Effectiveness parameters were the proportion of patients achieving psoriasis area and severity index (PASI) 50, 75, 90, and 100 response at week 16 and 24. Safety was measured as the proportion of patients reporting ≥1 adverse event (AE) during the study period. RESULTS: Data of a total of 70 patients were included in our study. At week 16, 76.92%, 41.53%, 15.38%, and 6.15% patients achieved PASI 50, 75, 90, and 100, respectively. At week 24, 81.53%, 58.46%, 29.23%, and 10.76% patients achieved PASI 50, 75, 90, and 100, respectively. Mean percentage reduction in PASI was 67% at week 24 and DLQI score was reduced significantly to 3.4 from mean baseline DLQI score of 10.8 (P < 0.001). 40% of patients reported ≥1 AE during the study period. 5 out of 70 patients discontinued apremilast due to AE. Nausea was most common AE reported by 21.4% patients followed by diarrhea (18.57%), headache (17.4%), vomiting (8%), weight loss (7.69%), myalgia (6.15%), and gastritis (6.15%). Most of the AEs were of mild-to-moderate severity. CONCLUSION: The results of this study support the long-term use of apremilast monotherapy as an efficacious and safe treatment option for the management of moderate-to-severe plaque psoriasis.

Leprosy Scenario in Ahmedabad District (Gujarat).

BACKGROUND: In India, leprosy still continues to be one of the major public health problems and demands a continuous awareness for its eradication. The reduction of the load of infection is the cornerstone of leprosy control. AIMS: The aim of the present study was to enumerate the epidemiology of leprosy in the Ahmedabad district of Gujarat. METHODS: Three hundred new cases of leprosy (multidrug therapy cases) and patients who had completed antileprosy treatment and developed new signs and symptoms after that during the period from June 2010 to December 2012 were included in the study. A detailed history, clinical examination, and relevant tests were done. RESULTS: Out of a total of 300 patients, male-to-female ratio was 2.1:1. Family history was positive in 4.3% of patients. Lepromatous leprosy was seen in 27.3%, pure neuritic leprosy occurred in 12 (3.9%), and smear positivity was seen in (44.6%). Thirty (10%) patients developed type 1 reaction and 32 (10.6%) patients had type 2 reaction. Nearly 1.3% of the cases were relapsing cases. LIMITATIONS: The study had geographical limitation and the study did not cater the whole population but only the cases who reported to the hospital. Hence, the social stigma factor associated with leprosy could not be annulled. CONCLUSIONS: Leprosy still prevails and adequate knowledge and clinical skills, sensitive diagnostic tools and proper supply of medicines from the medical end and early reporting of symptoms, compliance regarding medicine intake, and social awareness to null social stigma associated with it from the patient's end may bring the country as a whole to the target of leprosy elimination.

Apremilast in People Living with HIV with Psoriasis Vulgaris: A Case Report.

Psoriasis is a chronic papulosquamous skin disease that involves immune-mediated cutaneous inflammation and keratinocyte hyperproliferation. The associated immunosuppression in people living with HIV (PLHIV) with psoriasis poses a challenge to the clinician as therapeutic options are limited. Until now, there have been no documented case of apremilast therapy for HIV-associated psoriasis in India. Here, we report a case of HIV-associated psoriasis who achieved Psoriasis Area and Severity Index (PASI) 100 with apremilast therapy.

An Evaluation of Efficacy and Safety of Commonly Prescribed Drugs and Effect of These Drugs on Quality of Sleep in Patients Suffering From Zoster-Associated Pain.

This observational, prospective, single-center study was conducted to evaluate the efficacy and safety of commonly prescribed drugs for zoster-associated pain and their impact on quality of sleep at a tertiary care hospital in western India. Patients ≥18 years of age, newly diagnosed with zoster-associated pain were evaluated on days 0, 7, 14, 30, 60, 90, 120, 150, and 180 or until resolution of pain, whichever was earlier, using the Wong Baker FACES Pain Rating Scale, Neuropathic Pain Scale, and Insomnia Severity Index for intensity of pain, quality of pain, and quality of sleep, respectively. A total of 78 patients (46.0 [16.3] years) completed the study. They received nonsteroidal anti-inflammatory drugs (65), gabapentin (30), amitriptyline (27), and amitriptyline + gabapentin (21) for mean durations of 7.7 (3.0), 89.2 (7.2), 107.6 (46.3), and 104.5 (46) days, respectively. Improvement in the Wong Baker FACES Pain Rating Scale and Neuropathic Pain Scale score was similar among treatment groups except for a greater fall in Wong Baker FACES Pain Rating Scale score at days 7 and 120 and that in deep pain score at day 7 in combination treatment group vs the amitriptyline group. Clinically significant insomnia was detected in 35 patients at baseline and demonstrated progressive and similar improvement among groups. Treatment modification was required in 20 patients. Zoster-associated pain resolved in 69 patients. Nine adverse drug reactions, mostly mild, nonserious, and nonpreventable, were reported. To conclude, drugs commonly used for zoster-associated pain are effective and well tolerated. These have a similar effect on pain and quality of sleep, except for a possible greater effect of combination treatment in the early phase of intense and deep pain.