Low-dose Oral Minoxidil in the Treatment of Alopecia: Evidence and Experience-based Consensus Statement of Indian Experts.

Alopecia is a highly prevalent condition worldwide including in India. There are different types of alopecia with differing etiology, presentation, and hence treatment. Androgenetic alopecia represents the most common form of hair loss affecting male as well as female population termed as male and female pattern hair loss, respectively. Several treatment options are available for the treatment of alopecia with often unsatisfactory results resulting in psychological distress among such patients. Topical minoxidil is known to be effective in the treatment of alopecia. However, oral minoxidil is not currently approved for the treatment of alopecia. This expert consensus is prepared to provide guidance to the clinicians regarding the use of oral minoxidil in the treatment of alopecia. Extensive literature review was performed to prepare the draft consensus which was then revised based on the suggestions and comments from the experts. The final draft was circulated to the experts for review and approval. This consensus document provides overview of evidence related to oral minoxidil and consensus from the experts for its use in the treatment of minoxidil.

Use of Bleach Baths for Atopic Dermatitis: An Indian Perspective.

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disorder affecting 15-20% of children and 1-10% of adults. Staphylococcus aureus (S. aureus) infection is the most frequent complication of AD and is involved in the worsening of the disease. Systemic and topical antibiotics are used in the treatment for AD but there are concerns over increasing resistance. Bleach (sodium hypochlorite, NaOCl) baths are an inexpensive, widely accessible, alternative antibiotic treatment that may not worsen antibiotic resistance. Bleach baths are used as adjunctive treatment in AD patients to treat superinfections, although their mechanism of action is not well understood. Balancing safety concerns with efficacious treatment should be important especially for AD where the majority of patients are in pediatrics age groups. Studies available in PubMed databases were included in this review. Most suggested bleach bath improves clinical symptoms of AD and restores surface microbiome by eradicating bacteria, most notably S. aureus. Some studies have noted that this antimicrobial effect has reduced the need for topical corticosteroids. In addition, bleach seems to have strong anti-inflammatory and antipruritic effects. Overall, bleach baths seem to be safe on human skin, without disrupting the epidermal barrier function. The review concluded, although there are some advantages of use of bleach baths, more studies to investigate long-term efficacy and safety of bleach baths are required before fixing its role in the treatment of AD especially in the context of the Indian scenario.

Guidelines on Management of Atopic Dermatitis in India: An Evidence-Based Review and an Expert Consensus.

BACKGROUND: Atopic dermatitis (AD) is a common and chronic, pruritic inflammatory skin condition that affects all age groups. There was a dearth of consensus document on AD for Indian practitioners. This article aims to provide an evidence-based consensus statement for the management of AD with a special reference to the Indian context. This guideline includes updated definition, etiological factors, classification, and management of atopic dermatitis. METHODOLOGY: The preparation of guidelines was done in multiple phases. Indian Dermatology Expert Board Members (DEBM), recommended by the Skin Allergy Society of India, prepared 26 evidence-based recommendations for AD. An extensive literature search was done in MEDLINE, Google scholar, Cochrane, and other resources. Articles published in the past 10 years were reviewed and recommendations were graded based on the quality of evidence as per GRADE. After forming the initial structure, DEBM met in Mumbai and gave their decisions on an agree and disagree scale with an Indian perspective. Finally, their suggestions were compiled for preparing the article. After DEBM finalized the draft, a treatment algorithm was formulated for the management of AD. RESULTS: DEBM suggested a working definition for AD. The panel agreed that moisturizers should be used as mainstay of therapy and should be continued in all lines of therapy and in maintenance phase. Topical corticosteroids and topical calcineurin inhibitors should be considered as the first line of treatment. Among systemic therapies, cyclosporin should be considered first line, followed by azathioprine, methotrexate, and mycophenolate mofetil. Phototherapy can be an effecive alternative. Empirical food restriction was recommended against. CONCLUSION: These guidelines should form a reference for the management of patients with AD in an evidence-based manner.

Diagnosis and Management of Chronic Pruritus: An Expert Consensus Review.

The aim of this study is to formulate the best clinical practice in the diagnosis and management of chronic pruritus (CP). We searched PubMed, EMBASE, Scopus, Web of Science, and the WHO's regional databases, for studies on "Diagnosis and management of chronic pruritus" from January 1, 2014, to July 31, 2015. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data. We screened 87 of 95 studies that contained qualitative data. Avoid: Dry climate, heat, alcohol compress, ice packs, frequent bathing and washing, intake of very hot and spicy food, intake of alcohol, contact with irritant substances, excitement, strain and stress, and allergens. Using: Mild nonalkaline soaps, moisturizers, bathing oils, lukewarm water while bathing, soft cotton clothing and night creams/lotions, relaxation therapy, autogenic training, psychosocial education, educating patients to cope with itching and scratching, and educational programs. Especially use of moisturizers is considered important. In addition, symptomatic treatment options include systemic H1 antihistamines and topical corticosteroids. Symptomatic therapy directed toward the cause (hepatic, renal, atopic, polycythemia, etc.). If refractory or cause is unknown, consider capsaicin, calcineurin inhibitors for localized pruritus and naltrexone, pregabalin, ultraviolet therapy, Cyclosporine for generalized itching. CP is quite frequent finding associated with skin and systemic diseases in the overall population. It is known to significantly affect quality life score of an individual and also adds burden on the health-care cost. A specific recommendation for treatment of CP is difficult as a result of varied and diverse possibility of underlying diseases associated with CP.

Position statement for the use of omalizumab in the management of chronic spontaneous urticaria in Indian patients.

Chronic spontaneous urticaria (CSU) affects 1% of the world population and also their quality of life, and 50% of these patients are refractory to H1-antihistamines. Omalizumab is a humanized monoclonal anti-IgE antibody that binds with free IgE antibodies and reduces the circulating levels of free IgE. This reduction in free IgE prevents mast-cell degranulation. The EAACI/GA2LEN/EDF/WAO guidelines recommend omalizumab as the third-line of therapy as an add-on to antihistamines. The recommended dose of omalizumab is 300 mg, 4 weekly in the management of CSU refractory to standard of care with H1-antihistamines in adults and adolescents ≥12 years of age. In some patients, a dose of 150 mg may be acceptable. Omalizumab has a good safety profile. However, due to the biologic nature of the drug, all patients administered omalizumab must be observed for 2 h after administration for anaphylactoid reactions. There have been no studies on the effect of impaired renal or hepatic function on the pharmacokinetics of omalizumab. While no particular dose adjustment is recommended, omalizumab should be administered with caution in these patients.

Clinical patterns of vitiligo and its associated co morbidities: A prospective controlled cross-sectional study in South India.

AIM: The purpose of this study is to assess the clinical patterns and associations of vitiligo, audiometric functions, and ocular involvement and to correlate the morphology, clinical behaviour and comorbidities associated with vitiligo. SETTINGS AND DESIGN: For this prospective and cross-sectional study 80 self-reporting patients in the age group 7-75 years with vitiligo attending the outpatient department of Manipal hospital during the period August 2008 to February 2010 were selected and the data was analysed. MATERIALS AND METHODS: The patients were subjected to detailed history, clinical examination and investigations [complete blood count (CBC), absolute eosinophil count (AEC), erythrocyte sedimentation rate (ESR), thyroid stimulating hormone (TSH), vitamin B12 estimation, fasting blood sugar (FBS), and post prandial blood sugar (PPBS),antibody titre estimations that is antithyroid peroxidase (ATPA), antithyroglobulin (ATA), antinuclear antibodies (ANA),urine analysis], audiometric evaluation and ophthalmic examination. STATISTICAL ANALYSIS USED: The Fisher exact test has been used to find the significance of study parameters on categorical scale between two or more groups. RESULTS: In the present series of 80 cases, 41 (51.25%) were males and 39 (48.75%) were females. The male to female ratio was 1.05:1. In our study 20% cases gave definite family history of vitiligo and patients in the age group of 20 - 30 years were the most commonly affected. Generalized vitiligo (31.3%) was the most common type followed by segmental (30%), focal (18.8%), acrofacial (8.8%), and mucosal vitiligo (11.3%). In the present study there was a high incidence of autoantibodies (22.5%), vitamin B12 deficiency (30%), hypothyroidism (11.3%), elevated absolute eosinophil count (16.3%), hypoacusis (10%) and retinal changes (8.8%). This suggests multisystem autoimmunity in vitiligo.

Etiological approach to chronic urticaria.

BACKGROUND: In 1769, William Cullen introduced the word "urticaria" (transient edematous papules, plaque with itching). Urticaria affects 15-25% of people at least once in their life time. It is a clinical reaction pattern triggered by many factors causing the liberation of vasoactive substances such as histamine, prostaglandins and kinins. Urticaria is classified according to its duration into acute (< 6 weeks duration) and chronic (>6 weeks duration). Various clinical investigations may be initiated to diagnosis the cause. AIMS: To evaluate the types of chronic urticaria with reference to etiology from history and investigations. MATERIALS AND METHODS: A total of 150 patients with chronic urticaria of more than six weeks were studied. Autologous serum skin test (ASST) was performed after physical urticarias were excluded. Standard batteries of tests were performed after ASST in all patients; and other specific investigations were done where necessary. Skin prick test was done in idiopathic urticaria. RESULTS: The study sample consisted of 62 male and 88 female patients with a mean age of 21-40 years. About 50% of patients showed an ASST positive reaction, 3.9% were positive for antinuclear antibody (ANA), IgE titer was elevated in 37%, H. pylori antibodies was positive in 26.7%. Thyroid antibodies were positive in 6.2%. Giardia and entamoeba histolytica was reported in 3.3% on routine stool examination and on urinalysis 8% had elevated WBC counts; 12% showed para nasal sinusitis, with maxillary sinusitis of 7.3%. Random blood sugar was high in 5.3%. Four patients had ASOM, two had positive KOH mount for dermatophytes, abdominal USG showed cholecystitis in two patients. Recurrent tonsillitis was noted in two patients. Urticaria following intake of NSAIDs was observed in four patients and with oral contraceptive pills in one patient. Contact urticaria to condom (latex) was seen in one patient. Cholinergic (4.7%) and dermographic (4.7%) urticaria were the predominant physical urticarias. Prick test was performed in idiopathic urticaria with maximum reactions to food antigens (25%) where brinjal was the commonest, 9% to dust in which spider web was the most common, 8% to pollen where parthenium and amaranthus were the commonest, followed by A. flavus in fungi, pigeon in epithelia and cockroach in insects. CONCLUSION: Nearly half of the patients had chronic autoimmune urticaria on the basis of ASST. A significant number of them had serological makers of autoimmune activity. ASST provides an easy, inexpensive investigation in CU and helps direct attention to underlying systemic auto immune diseases. The presence of these auto antibodies was significantly associated with more frequent and longer lasting urticarial attacks. Exhaustive work ups with extensive laboratory diagnostics, challenge tests, and prick testing should be reserved for individual cases following detailed history.

Atopic patch testing.

BACKGROUND: Atopic dermatitis is a major problem among the urban population and it can be aggravated or triggered by various allergens. Atopic patch test can be used as a diagnostic tool in characterizing patients with allergen triggered atopic dermatitis. AIMS: 1. Patch testing to reproduce an eczematous reaction by applying prick test allergens under occlusion on intact skin. 2. To find the allergen associated with atopic dermatitis. 3. To find the specific allergen which causes or exacerbates atopic dermatitis in a given subject. METHODS: Seventy five subjects with atopic dermatitis were included in our study and patch tests using prick test allergens were applied to the back. Reading was done after 48 and 72 hours RESULTS: Out of the 75 subjects tested, 47% showed positive reactions, parthenium accounted for 42% of all positive reactions. CONCLUSIONS: Epicutaneous application of prick test antigen on intact skin can produce a reaction. Parthenium is commonest allergen in Bangalore. Counselling based on patch test reports may help to reduce morbidity and improve quality of life.

Role of cortisol on condition factor in the female freshwater fish, Notopterus notopterus during four reproductive phases.

The condition of the female fish, Notopterus notopterus was studied during four phases of the reproductive cycle in control and after cortisol hormone treatment. The condition of the fish including condition factor (K) and somatic condition factor (Ks) was determined based on weight of the body, length of the fish and gonad weight. In control fish the condition of the fish improve during prespawning phase compared to other phases. The hormone cortisol level estimated by radioimmunoassay (RIA) technique was found to be increased in preparatory and decreased during prespawning phase, may be because of the hormone involvement in metabolic activity, vitellogenesis. In cortisol treatment, the condition of the fish decrease during prespawning phase, compared to other phase may be because of extra expenditure of energy for progressing reproductive activity such as vitellogenesis.

Tissue cholesterol and serum cortisol level during different reproductive phases of the female freshwater fish Notopterus notopterus (Pallas).

In the present study tissue cholesterol and serum cortisol changes during two reproductive phases have been correlated in the freshwater fish Notopterus notopterus. The reproductive cycle of N. notopterus has two phases such as breeding phase (April - August) and non breading phase (October - December). The cholesterol content of the ovary and liver increased during breeding phase. The serum cortisol estimated by radio immuno assay (RIA) technique indicates that the level of the hormone was high during breeding phase compared to non breading phase. The increase in cholesterol during breeding phase may be because of increase in cortisol synthesis needed for ovarian growth and vitellogenesis. The gonadosomatic index (GSI) also increases during breeding phase.

Leg ulcers due to hyperhomocysteinemia.

Chronic leg ulcers are rare in young adults and generally indicate a vascular cause. We report a case of a 26-year-old man with leg ulcers of eight months duration. Doppler study indicated venous incompetence and a postphlebitic limb. However, as the distribution and number of ulcers was not consistent with stasis alone and no features of collagen vascular disease were noted, a hyperviscosity state was considered and confirmed with significantly elevated homocysteine level in the serum. Administration of vitamins B1, B2, B6 and B12, trimethyl-glycine, mecobalamine, folic acid and povidone iodine dressings with culture-directed antibiotic therapy led to a satisfactory healing of ulcers over a period of one month. Hyperhomocysteinemia must be considered in the differential diagnosis of leg ulcers in young individuals.

Effect of cortisol on female freshwater fish Notopterus notopterus.

In the present study, effect of cortisol on the ovary of the freshwater fish Notopterus notopterus was studied during four phases of the reproductive cycle. The hormone was injected 60microg/fish for ten days. Cortisol in fish is known to increase the metabolic activity. After the hormone treatment the ovarian somatic index and the hepatosomatic index increases during non breeding phase. The young oocytes transferred into vitellogenic oocytes in all the phases after cortisol treatment. The cortisol induced increased ovarian activity may be due to increase in the metabolic activity through the involvement of hepatic cells specially during non-breeding period providing support for energy production for reproductive activity in the freshwater fish N. notopterus.

Somatic condition of the fish, Notopterus notopterus (Pallas) during different phases of the reproductive cycle.

The study on the mathematical relationship between length and weight of fishes has considerable importance in fishery research especially for the study of fish population dynamics and patterns of growth in fish stocks. This aspect is useful in rationally managing the population of fishes, and is an index of relative robustness of the fish). Variations from expected weight or length of an individual fish or group of fish indicate the general well being and state of gonadal development. The condition of fish can be influenced by the onset of maturity. The results indicate that the overall condition of the female and male fish seems to get improved towards the approach of maturing and mature stages of the gonads during pre-spawning phases. The reduction in the condition factor (K) and somatic condition factor (Ks) during spawning phase may be because of the fish becoming exhausted due to spawning activity. Although improvement in the condition of the fish was observed on the approach of breeding period, the overall condition seems to be better in the aquatic body from which the fish was collected.

Changes in tissue cholesterol and serum cortisol level during four reproductive phases of the male freshwater fish, Notopterus notopterus.

The tissue cholesterol and serum cortisol changes during four reproductive phases has been studied in the freshwater fish Notopterus notopterus of male sex during four phases, preparatory (January - March), prespawning (April - May), spawning (August - September) and post spawning (November - December). The cholesterol content of the testis and liver increased during preparatory phase and maximum content of cholesterol was during spawning phase. The serum cortisol estimated by radioimmunoassay (RIA) technique which indicated that the level of the hormone was high during pre-spawning and spawning phases compared to other two phases. The increase in cholesterol during preparatory and spawning phases may be because of increase in cortisol synthesis needed for testicular growth and spermetogenesis during these phases. The gonadosomatic index (GSI) also increased during these phases.

Relevance of patch testing in patients with nummular dermatitis.

BACKGROUND: A chronic dermatosis like nummular dermatitis may be complicated by contact dermatitis due to an impaired cutaneous barrier. This study is aimed at evaluating secondary contact dermatitis in patients with nummular dermatitis. METHODS: Patch testing with the Indian Standard Series was performed in 50 of 78 patients with a clinical diagnosis of nummular eczema. Significant reactions were graded as per ICDRG criteria. RESULTS: Significant reactions were noted in 23 of 50 tested patients. The most frequent sensitizers were colophony, nitrofurazone, neomycin sulfate and nickel sulfate (7.14% each). Reactions to antigens in topical medications, cosmetics and toiletries constituted 64.28% of all the reactions. CONCLUSIONS: Patients with nummular dermatitis are at significant risk of developing secondary allergic contact dermatitis, which contributes to the severity and chronicity of their dermatitis. Patch testing has the potential to improve the quality of life in these patients. Hence, patients with chronic recalcitrant nummular dermatitis must be patch tested.

Dermatologic surgery: pulsed erbium:YAG laser-assisted autologous epidermal punch grafting in vitiligo.

BACKGROUND: A pilot study was conducted to evaluate the efficacy and safety of pulsed erbium:YAG laser ablation of autologous minipunch grafted sites for the treatment of refractory or stable vitiligo. METHODS: Thirteen patients, seven men and six women, aged between 19 and 58 years, with Fitzpatrick skin types ranging from type IV to VI, were grafted. The pulsed erbium: YAG laser was used to create recipient graft sites. RESULTS: Repigmentation was observed in 12 out of 13 patients. Failure of grafts to repigment ranged from 3% to 100%. No untoward side-effects of surgery were noted. CONCLUSIONS: Using an erbium:YAG laser to create graft recipient sites permits the survival of punch harvested grafts and the spread of pigmentation to the surrounding skin.

Effect of cortisol on testis of freshwater fish Notopterus notopterus (Pallas).

Cortisol (20, 40 and 60 micrograms/fish for 10 days) treatment caused an increase in testicular-somatic index (TSI) in immature N. notopterus whereas in mature fish no change from that of controls was observed. Histology of testis indicated that spermatogenetic activity was activated in immature fish while it was inhibited in mature fish. Testicular cholesterol exhibited a similar response. The results indicate that cortisol inhibits spermatogenesis during mature phase while it promotes spermatogenesis during immature phase of the reproductive cycle in N. notopterus.

Congenital leukaemia presenting with skin nodules.

A 2-month-old infant presented with the skin nodules of 1½ months duration. Routine investigation and bone marrow examination showed the presence of myeloblastic Ieukaemia-M4 type, FAB classification.