Oral Mucosal Lesions - A Study of 369 Cases.

Background: Diagnosing and treating oral cavity lesions is a challenging task for most of the clinicians due to similar symptoms and clinical appearances. Frequently, histopathology and immunohistochemistry aid in making the diagnosis. Objectives: The objectives were to describe the clinical features, and histopathological features and systemic association in patients with oral mucosal lesions (OML). Materials and Methods: A cross-sectional descriptive study was undertaken at a tertiary care centre in patients with OML. A total of 369 cases with OML were included in the study. Results: Males constituted 61.78% of the cases. History of habits such as tobacco, gutka chewing, smoking, and alcohol was given by 32.25%, 29.81%, 26.56%, and 11.38% of cases, respectively. Common symptoms were soreness, burning sensation, oral pain and ulcers. Both oral and cutaneous involvement was seen in 17.89% of cases. Oral lichen planus (oral LP) constituted largest group of patients (21.96%) wherein reticulate type was the most frequent type and buccal mucosa was the commonest site. Oral carcinomas constituted 20.33% of cases followed by infective etiology (11.92%), vesiculobullous group of diseases (10.30%), aphthous stomatitis (8.94%), premalignant lesions (7.05%) such as leukoplakia (3.80%) and submucous fibrosis (2.44%). Histopathology was done in 209 cases. Clinico-histopathological correlation was seen in oral LP (90.27%), oral pemphigus (82.35%), and malignancies (98.66%). Conclusion: Oral LP formed the largest group of cases followed by Oral squamous cell carcinoma (SCC). Several rare conditions, such as Melkersson-Rosenthal syndrome and blue rubber bleb nevus syndrome were also a part of the study. Thorough clinical and histopathological examination in this diverse group of diseases clinches the diagnosis.

Efficacy of Intralesional Measles Mumps Rubella Vaccine in the Treatment of Verruca Vulgaris: An Interventional Study.

Background A wart is a mucocutaneous illness caused by the growth of HPV-infected skin or mucosal cells. Intralesional immunotherapy makes use of the immune system's ability to identify injected antigens, which might cause a delayed-type hypersensitivity reaction not just to the antigen but also to the wart virus. This, in turn, improves the immune system's ability to identify and eliminate HPV not just at the treated wart but also at distant places, as well as prevent recurrences. Aims and objectives To study the efficacy of the intralesional measles, mumps, and rubella (MMR) vaccine in verruca vulgaris and its side effects. Materials and methods Interventional research with a 94-case sample size was conducted over a period of seven months. A volume of 0.3 ml of the MMR vaccination was reconstituted with sterile water and injected into the largest wart at three-week intervals until complete clearance or for a maximum of three treatments. Following a six-month observation period, patients were evaluated to look for recurrence, and the degree of response was categorized as total, partial, or none at all. Results The youngest case included in the study was of age 10 years and the eldest case was of 45 years. The mean age was 28.22± 10.98. Of 94 patients, 83 (88.3%) were men and 11 (11.7%) were women. Complete remission was reported in 38 (40.42%) cases, a partial response in 46 (48.94%) cases, and no response in 10 (10.63%) cases. All 38 patients who showed complete clearance had a duration of warts in six months or less. The pain was a universal complaint (100%) after each visit followed by bleeding at 25.53%. Flu-like symptoms were noted in three cases after the first dose and two cases after the second dose, while urticaria was seen in one case during all visits. Cervical lymphadenopathy was observed in two cases after the first dose. Erythema multiforme minor was seen only in one patient after the first dose. Conclusion Intra-lesional MMR vaccine therapy proved to be a simple and safe treatment option in cases having multiple warts. The response rate may increase if a higher concentration of vaccine (0.5ml) and additional doses (maximum of five doses) are given.

Eponymous Signs in STIs.

Eponymous medical signs are those that are named after a person or persons, usually the physicians who first described them, as a tribute to the pioneers in the field who have significantly contributed toward the present understanding of the subject. They also help in providing an easy milieu for remembering the particulars of disease with their diagnostic significance including signs, tests, criteria, laws, or reflexes. Besides paying tributes to stalwarts in the field, who dedicated their lives for this cause, they also facilitate our current understanding of the great masquerade.

Male circumcision and Sexually transmitted Infections - An update.

Role of male circumcision (MC) as a tool to prevent sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) was assessed. An attempt was made to search articles related to association between MC and STIs/HIV. A thorough search was carried out to find out quality articles published in indexed specialty journals. Centers for Disease Control and Prevention and World Health Organization (WHO) sites were also referred. Warm and moist environment of area under foreskin facilitates some pathogens to persist and replicate. Further, the thinness of foreskin predisposes it to minor trauma and abrasions that facilitate the entry of pathogens. MC reduces HIV infection risk by 50%-60% over time and reduces the risk of men acquiring herpes simplex virus-2 and human papillomavirus (HPV) that can cause penile and other anogenital cancers, by 30%. There is no significant reduction in risk of acquiring syphilis, but reduced risk of acquisition of Haemophilus ducreyi is reported. MC is reported to be beneficial in conditions such as traumatic injury, Balanitis Xerotica Obliterans, refractory balanoposthitis, and chronic, recurrent urinary tract infections. MC also reduces the chances of penile carcinoma by facilitating improved penile hygiene, lowering HPV/HIV transmission rates, and reducing chronic inflammatory conditions such as phimosis and balanitis. MC has been recommended by the WHO and UNAIDS in 2007 as an additional HIV prevention intervention in settings of high HIV prevalence. MC is an important adjunct to safe sex education, condom use, and vaccination (HPV) in reducing the global burden of HIV/STIs-related morbidity and mortality.

A Comparative Study of Intralesional Vitamin D3, Measles Mumps Rubella Vaccine, and Tuberculin Purified Protein Derivative in the Treatment of Recalcitrant Warts: An Approach to Solve a Therapeutic Conundrum.

BACKGROUND: Human papilloma virus infects and proliferates in skin or mucosal cells to cause warts. Most of the current therapeutic modalities are ablative, act only on treated lesions, and lack a well-defined treatment endpoint. These being blind procedures, recurrence rates are high, owing to the remnant virus. Intralesional immunotherapy plays a significant role, as it potentially acts on treated and distant lesions. OBJECTIVES: We sought to study and compare the efficacy, safety profile, and recurrence rates of intralesional immunotherapy modalities (vitamin D3; measles, mumps, and rubella [MMR] vaccine; and tuberculin purified protein derivative [PPD]) in treating viral warts. METHODS: An open-label interventional study of 60 cases of cutaneous viral warts was performed in a tertiary care center attached to a medical college after obtaining approval from the institutional ethics committee. Each patient was consecutively assigned into Group 1 (vitamin D3: 0.2mL of 15mg/mL), Group 2 (MMR: 0.5mL), or Group 3 (tuberculin PPD: 0.1mL of 10TU). One or two warts were injected per session every two weeks. Response was assessed. Adverse effects were noted. Cases were followed up monthly for three months. RESULTS: The MMR group had the maximum patients with complete response (15 of 20, 75%) followed by tuberculin PPD group (13 of 20, 65%) and vitamin D3 group (12 of 20, 60%). No major adverse drug reactions were reported in any of the groups. CONCLUSION: Immunotherapy offers a safe and promising approach in patients with extensive cutaneous viral warts in difficult to treat sites.

Hypertrophic lichen planus of the vulva - A missed diagnosis.

Lichen planus (LP) is an inflammatory dermatosis which can affect the skin, nails, and all mucous membranes, including the genitalia. Lichen planus on vulvar keratinized skin can manifest with diverse clinical features, probably due to higher temperature, PH, humidity, and bacterial flora which may modify typical cutaneous features. While lichen planus (LP) may affect the vulva in isolation, it may also be part of generalized outbreak in up to 20% cases. Herein, a case of a 53 year-old female who presented with a severely pruritic plaque over labia majora Since 6 -7 months, with no response to potent topical corticosteroids is reported. Provisional diagnosis of lichen simplex chronicus was considered however, histopathology was suggestive of hypertrophic lichen planus.

Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task Force against Recalcitrant Tinea (ITART) Consensus on the Management of Glabrous Tinea (INTACT).

BACKGROUND AND AIMS: Dermatophytosis has always been a common superficial mycosis in India. However, the past 6-7 years have seen an unprecedented increase in the number of patients affected by recurrent, chronic, recalcitrant and steroid modified dermatophytosis involving the glabrous skin (tinea corporis, tinea cruris and tinea faciei). Importantly, there has been a notable decrease in clinical responsiveness to commonly used antifungals given in conventional doses and durations resulting in difficult-to-treat infections. Considering that scientific data on the management of the current epidemic of dermatophytosis in India are inadequate, the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task force Against Recalcitrant Tinea (ITART) has formulated a consensus statement on the management of dermatophytosis in India. METHODS: Seventeen dermatologists with a focussed interest in dermatophytosis participated in a Delphi consensus method, conducted in three rounds. They responded as either "agree" or "disagree" to 132 statements prepared by the lead experts and gave their comments. Consensus was defined as an agreement of 80% or higher concurrence. Statements on which there was no consensus were modified based on the comments and were then recirculated. The results were finally analysed in a face-to-face meeting and the responses were further evaluated. A draft of the consensus was circulated among the participants and modified based on their inputs. RESULTS: Consensus was achieved on 90 of the 132 statements. Direct microscopy using potassium hydroxide mount was recommended in case of diagnostic difficulty on clinical examination. Counselling of patients about strict adherence to general measures and compliance to treatment was strongly recommended as the key to successful management of dermatophytosis. A combination of systemic and topical antifungal drugs was recommended for the treatment of glabrous tinea in the current scenario. Topical corticosteroid use, whether used alone or in combination with other components, was strongly discouraged by all the experts. It was suggested that topical antifungals may be continued for 2 weeks beyond clinical resolution. Itraconazole and terbinafine were recommended to be used as the first line options in systemic therapy, whereas griseofulvin and fluconazole are alternatives. Terbinafine was agreed to be used as a first line systemic agent in treatment naïve and terbinafine naïve patients with glabrous tinea. Regular follow-up of patients to ensure compliance and monitoring of clinical response was recommended by the experts, both during treatment and for at least 4 weeks after apparent clinical cure. Longer duration of treatment was recommended for patients with chronic, recurrent and steroid modified dermatophytosis. CONCLUSION: Consensus in the management of dermatophytosis is necessary in the face of conventional regimens proving ineffective and dearth of clinical trials re-evaluating the role of available antifungals in the wake of evolving epidemiology of the infection in the country. It needs to be backed by more research to provide the required level of evidence. It is hoped that this consensus statement improves the quality of care for patients with dermatophytosis, which has emerged as a huge public health problem, imposing considerable financial burden on the country.

Behcet disease - A nonvenereal cause of genital ulceration.

Behcet's disease (BD) is a chronic, relapsing, inflammatory vascular disease with no diagnostic or pathognomonic test. Here, we present a case of 26-year-old male with a complaint of recurrent oral, genital, and cutaneous lesions. The diagnosis of BD was confirmed on the basis of revised the International Criteria for BD. The case was treated satisfactorily with systemic corticosteroid in the tapering dose and oral Dapsone.

Genital lichen sclerosus et atrophicus in females: An update.

Lichen sclerosus et atrophicus is an acquired chronic inflammatory dermatosis commonly affecting the vulvar and perianal regions. It is associated with an increased risk of vulvar cancer even though it is not a premalignant condition itself. The true precursor of cancer associated with lichen sclerosus (LS) is vulvar intraepithelial neoplasia (VIN), differentiated type. The diagnosis is usually clinical, but in some cases, a biopsy can be performed, especially to exclude VIN or cancer. All females with anogenital LS can be offered clobetasol propionate 0.05% ointment on a regimen for 3 months (once a day for a month, followed by alternative days for a month, and then, twice weekly for a month), combined with a soap substitute and a barrier preparation.

Genital lichen planus: An underrecognized entity.

Genital lichen planus (LP) is an underrecogonized dermatosis. The appearance is often unlike classical LP elsewhere, and hence, the condition goes undiagnosed in many. Vulvo-vaginal LP in particular, can be a distressing condition often leading to scarring and a poor quality of life. Treatment for most of the genital LP variants is similar to managing LP elsewhere; however, the erosive variant requires special attention as treatment outcomes are often disappointing and the disease runs a protracted course. Potential for development of malignancy also exists, as in oral LP, and hence close follow up is essential.

Verrucous lesions over external genitalia as a presenting feature of pemphigus vegetans.

Pemhigus vegetans is a rare variant of pemphigus vulgaris which primarily occurs in the flexures of the body. We report a case of pemphigus vegetans in an 85-year-old female presenting with hypertrophic verrucous lesions over external genitalia and perianal region. There was no history of preceding oral lesions. The diagnosis of pemphigus vegetans was considered on the clinical ground and confirmed by histopathological examination.

Epidemiological, clinical, and immunological profile of cases at the time of HIV testing (a clinic-based observational cross-sectional study).

INTRODUCTION: With the availability of free antiretroviral therapy (ART), HIV/AIDS has become a chronic manageable disease, but its transmission still continues. Early testing, though desirable, is still a far-fetched goal. MATERIALS AND METHODS: Forty-six newly detected HIV cases attending skin and sexually transmitted disease (STD) outpatient department (OPD) were studied. Careful inquiry was made to know the reason for HIV testing, marital status, concordance rate in married couples, and CD4 count at the time of presentation. RESULTS: Of the 46 cases, 27 (59%) cases were in the age range of 20-40 years with 41% females and 59% males. Forty-one cases were married and cohabiting, out of which 19 were seroconcordant. Condom was used by 5/19 cases in seroconcordant group and 3/22 cases in serodiscordant group. Fourteen (30.4%) cases were tested for an epidemiologic reason (the most common being spouse positivity and antenatal care testing). Of the remaining 32 cases, the reason for testing was mucocutaneous manifestations in 16 cases, STD in 10 cases, and systemic illnesses (fever of unknown origin and weight loss) in 6 cases. Mean CD4 count was 336/cumm, with 17 cases having CD4 count <250/cumm. CONCLUSION: Except one, all cases were tested either because they were symptomatic or were referred by health-care provider for epidemiologic reasons. The presence of mucocutaneous manifestations including STD and systemic illnesses as the reason for testing as well as low CD4 count at the time of testing suggest less and late testing. Low condom use and high STD rate in married couple imply continued intramarital transmission. Although HIV seropositivity offers an entry point into continuum of comprehensive care package which includes free ART, it appears that HIV testing is still less and late.

Association of interleukin 1 receptor antagonist intron 2 variable number of tandem repeats polymorphism with vitiligo susceptibility in Gujarat population.

BACKGROUND: Vitiligo is a multifactorial, polygenic, autoimmune skin disorder caused by selective destruction of melanocytes. Interleukin 1 receptor antagonist intron 2 polymorphism was found to be associated with various autoimmune disorders. AIMS: We aimed to investigate the association of interleukin 1 receptor antagonist intron 2 variable number of tandem repeats polymorphism (rs2234663) with vitiligo to assess interleukin 1 receptor antagonist transcript levels and to perform possible genotype-phenotype correlation. METHODS: Three hundred and seven vitiligo patients and 316 controls were enrolled in the study, genotyping of interleukin 1 receptor antagonist rs2234663 was performed by polymerase chain reaction, and relative gene expression of interleukin 1 receptor antagonist was carried out in peripheral blood mononuclear cells from patients (n = 36) and controls (n = 36) by real-time-PCR. RESULTS: A significant difference was observed in the frequency of interleukin 1 receptor antagonist *A (1/2) genotype among patients with active and stable vitiligo (P = 0.0172). Interleukin 1 receptor antagonist*A (2/2) genotype and allele frequencies were significantly different between SV patients and controls (P = 0.0246 and P = 0.0046, respectively). Significant difference was also observed for interleukin 1 receptor antagonist*A2 (allele) in active and stable vitiligo patients (P = 0.0060). However, other comparisons did not show any significant difference in genotype and allele frequencies. Moreover, interleukin 1 receptor antagonist*A (3/2) genotype was observed only in patients whereas interleukin 1 receptor antagonist*A (5/2) was observed only in controls. Gene expression analysis showed no significant difference in interleukin 1 receptor antagonist transcript levels in patients compared to controls (P = 0.5962). Interestingly, genotype-phenotype correlation analysis revealed that individuals with IL1RN*A (2/2) exhibited higher interleukin 1 receptor antagonist expression compared to other major genotypes interleukin 1 receptor antagonist*A (1/2) (P = 0.01) and interleukin 1 receptor antagonist*A (1/1) (P = 0.03). LIMITATIONS: More case-control studies on interleukin 1 receptor antagonist rs2234663 polymorphism and gene expression from different ethnic populations are required to explore the impact of interleukin 1 receptor antagonist in vitiligo susceptibility. CONCLUSION: Interleukin 1 receptor antagonist*A2 might be a risk factor for progressive vitiligo.

Association of elevated homocysteine levels and Methylenetetrahydrofolate reductase (MTHFR) 1298 A > C polymorphism with Vitiligo susceptibility in Gujarat.

BACKGROUND: Several studies have reported hyperhomocysteinemia in vitiligo patients, suggesting the potential role of elevated homocysteine levels in precipitating vitiligo. OBJECTIVES: We aimed to estimate homocysteine and vitamin B12 levels, and to investigate the role of MTHFR 677 C > T and 1298 A > C polymorphisms in vitiligo susceptibility in Gujarat population. METHODS: Homocysteine and vitamin B12 levels were estimated in plasma of 55 vitiligo patients and 60 controls by Electrochemiluminescence immunoassay (ECLIA). Polymerase chain reaction- restriction fragment length polymorphism (PCR-RFLP) and amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) techniques were used to genotype MTHFR 677 C > T and 1298 A > C polymorphisms in 520 vitiligo patients and 558 controls. RESULTS: Our results showed significantly elevated homocysteine levels (p = 0.0003) as well as significant decrease in vitamin B12 levels (p = 0.0102) in vitiligo patients, as compared to controls. No significant difference in genotype and allele frequencies of MTHFR 677 C > T polymorphism was observed among patients and controls, however, the frequency of 'CC' genotype of MTHFR 1298 A > Cpolymorphism was significantly increased in patients as compared to controls (p = 0.0151). Analysis based on the type of vitiligo revealed a significant increase in 'C' allele of MTHFR 1298 A > C polymorphism in patients with generalized (p = 0.003) and active (p = 0.007) vitiligo as compared to controls. Both the polymorphisms of MTHFR were in low linkage disequilibrium (LD) and susceptible 'TC' haplotype was more frequently observed (p = 0.008) in vitiligo patients. Interestingly, elevated homocysteine levels were also positively correlated with MTHFR 1298 A > C polymorphism in vitiligo patients. Structure based in silico prediction revealed structural perturbations in MTHFR protein due to Ala222Val and Glu429Ala amino acid substitution. CONCLUSIONS: The present findings suggest that MTHFR 1298 A > C polymorphism and, altered homocysteine and vitamin B12 levels might play a vital role in the precipitation of vitiligo.