Indian Journal of Dermatology
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   Table of Contents - Current issue
May-June 2018
Volume 63 | Issue 3
Page Nos. 193-279

Online since Monday, May 21, 2018

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Association between psoriasis and Helicobacter pylori infection: A systematic review and meta-analysis Highly accessed article p. 193
Wai Chung Yong, Sikarin Upala, Anawin Sanguankeo
Background/Purpose: Helicobacter pylori infection has been suggested as a culprit of various extragastrointestinal (GI) disorders. It is debatable whether H. pylori infection exacerbates or triggers the pathogenesis of psoriasis. This meta-analysis aimed to explore the association between psoriasis and H. pylori infection. Materials and Methods: A comprehensive search of the MEDLINE and EMBASE databases was performed from inception through October 2017. The inclusion criterion was observational studies evaluating the association between psoriasis and H. pylori infection. The pooled odds ratio (OR) of H. pylori infection and their 95% confidence interval (CI) were calculated using a random-effects meta-analysis to compare risk between psoriasis patients and controls. The between-study heterogeneity of effect-size was quantified using the Q statistic and I2. Results: Data were extracted from nine observational studies involving 1546 individuals. Pooled result demonstrated an increased H. pylori infection in psoriasis compared with controls (OR=1.58; 95% CI: 1.02–2.46, P=0.04, I2=64%). Subgroup analysis showed an increased risk of H. pylori infection in psoriasis measured with H. pylori IgG enzyme-linked immunosorbent assay (OR=3.11; 95% CI: 1.85–5.20, P<0.01, I2=10%) but not active infection measured with urea breath test (OR=0.88; 95% CI: 0.61–1.27, P=0.49, I2=0%). Conclusion: This meta-analysis has shown an increased H. pylori infection in patients with psoriasis. H. pylori infection in the past could play a role in the abnormal immunological cascade in the pathogenesis of psoriasis. Further studies to elucidate the inflammatory response in the pathogenesis of psoriasis are warranted.
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The effect of Candida albicans on the expression levels of toll-like receptor 2 and interleukin-8 in HaCaT cells under High- and Low-glucose conditions p. 201
Di Wang, Yong Jiang, Zhuoran Li, Lu Xue, Xiaoting Li, Yuanjun Liu, Chunli Li, Huiping Wang
Background: The diabetics are prone to skin infections, especially with Candida albicans. It is important to elucidate the different antifungal abilities of patients with hyperglycemia and healthy controls for the treatment of this condition. The toll-like receptor 2 (TLR2) and interleukin (IL)-8 secreted by keratinocytes counteract C. albicans. Aim: This study aims to explore the differential expression of toll-like receptor 2 (TLR2) and interleukin (IL)-8 secretion by keratinocytes between controls and diabetic patients when challenged with C. albicans. Materials and Methods: HaCaT cells were cultured in high-glucose (HG) Dulbecco's modified Eagle's medium (DMEM) and low-glucose (LG) DMEM. Then, they were exposed to C. albicans hyphae for 24 h. The expression levels of TLR2 and IL-8 were determined at different periods in both the HG and LG groups. Real-time polymerase chain reaction analysis, western blotting, and enzyme-linked immunosorbent assays were performed in this study. The morphological changes of HaCaT cells under two different glucose concentrations were also observed. Results: We found that the expression levels of both TLR2 and IL-8 increased and then decreased in the two groups. Notably, the IL-8 levels in the LG group were higher than those in the HG group at each time point (P<0.05), and the TLR2 levels in the LG group were higher than those in the HG group at the beginning of the experiment and after 24 h of treatment with C. albicans (P<0.05). In each group, the levels of IL-8 and TLR2 at the secretion peak were significantly different from those in the initial and the last period of observation (P<0.05). The cellular morphology of HaCaT cells treated with different concentrations of glucose was also similar. However, with prolonged coculture time, cell death increased. Conclusion: These observations showed that TLR2 and IL-8 act on the keratinocytes interacting with C. albicans, and HG status might affect the function of HaCaT cells by reducing the secretion of IL-8 and TLR2.
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The role of forkhead box class O3A and SIRT1 gene variants in early-onset psoriasis p. 208
Suzan Demir Pektas, Gursoy Dogan, Tuba Gokdogan Edgunlu, Sevim Karakas-Celik, Esra Ermis, Nilgun Solak Tekin
Background: Psoriasis is a chronic inflammatory skin disorder, which is characterized by a heightened immunological response. Although the immunogenetics of this chronic inflammatory disorder is poorly understood, its expression is known to be dependent on proinflammatory cytokines. It is known that two distinct subtypes of chronic plaque psoriasis: Early-onset psoriasis (EOP) before the age of 40 years and late-onset psoriasis after the age of 40 years. Forkhead box class O3A (FOXO3A) is a transcription factor, which plays an important role in cell-cycle regulation, apoptosis, oxidative stress, and DNA repair. The silent information regulator (SIRT) is thought to have a role in skin disorders, including psoriasis, that are characterized by hyperproliferation and inflammation. Aim: The aim of this study was to investigate FOXO3A and SIRT1 gene polymorphisms in EOP. Methods: The study group consisted of 142 EOP patients and 123 unrelated healthy controls. FOXO3A polymorphisms were determined using the polymerase chain reaction (PCR)-restriction fragment length polymorphism method. SIRT1 gene polymorphisms were determined by PCR-confronting two-pair primers methods. Results: The FOXO3A rs4946936 and SIRT1 rs7069102 gene polymorphisms were positively correlated with EOP and disease severity. The GG genotype frequency of SIRT1 rs7069102 gene polymorphisms was increased in severe EOP. The CC frequency of FOXO3A rs4946936 was increased in EOP with nail disorders. Conclusion: The rs7069102 gene polymorphism of SIRT1 and rs4946936 polymorphism of FOXO3A are associated with early onset psoriasis; this may be responsible for increased keratinocyte proliferation in the pathogenesis of psoriasis and disease severity.
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Study of S100 immunostaining in demonstrating neural granulomas in paucibacillary leprosy p. 215
Nandini Shenoy, Nandakumar Gopinathan Nair
Context: Neural granulomas are hallmark of leprosy. Challenges faced in diagnosing paucibacillary leprosy include: (i) Difficult visualization of nerve twigs on hematoxylin and eosin (H and E) sections due to their small size and (ii) Paucity of organisms on acid–fast bacilli stain. Aims: (1) This study aimed to test the role of S100 immunostain in demonstrating neural granulomas in skin biopsies of paucibacillary leprosy, (2) to compare morphology of S100 staining of nerves inside granulomas among clinicohistologically defined different types of leprosy, and (3) to test whether the pattern of S100 immunostaining can distinguish nerve fragmentation/destruction from a normal intact nerve in skin biopsy. Materials and Methods: Sixty four diagnosed cases of leprosy were included in this study. Five skin biopsies with no significant pathology (for studying intact nerve) and nine nonleprosy cutaneous granulomas were also studied. Results: (i) In demonstrating neural granuloma, sensitivity of H and E was 48.27% and that of S100 was 100%, (ii) Morphology of nerve fragments on S100 stain for cases of leprosy was fragmented and infiltrated in 37, intact and infiltrated in 19, reduced, fragmented, and infiltrated in seven, and absent in one, (iii) There was a significant difference (P<0.001) in the pattern of staining of S100 on intact nerve and nerves involved by granuloma in leprosy, and (iv) The probability to differentiate between leprosy and nonleprosy granuloma was statistically significant (P<0.001). Conclusion: S100 immunostaining showed to be an effective adjuvant to histopathology in diagnosing paucibacillary leprosy and differentiating it from nonleprosy cutaneous granuloma.
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Polymorphism of FAS and FAS ligand genes in alopecia areata: A case–control study in Egyptian population p. 220
Iman Seleit, Ola Ahmed Bakry, Eman Abd El Gayed, Abd El D Gawad
Background: Alopecia areata (AA) is a common dermatologic disease with suspected autoimmune etiology. Tumor necrosis factor superfamily member 6 or CD95 (FAS) and FAS ligand (FASL) are proapoptotic proteins. The relationship between apoptosis and autoimmunity is well recognized. Inflammatory T cells in AA are cytotoxic and possess FAS/FASL antigens. Aim: This study aims to investigate the association between FAS-670 A/G and FASL-124 A/G gene polymorphisms and AA to clarify if these polymorphisms influence disease occurrence or increase disease risk. Materials and Methods: A case–control study was conducted on sixty patients with AA, and 40 age- and sex-matched healthy subjects, as a control group. Disease severity was assessed by severity of alopecia tool (SALT) Score. FAS 670A/G and FASL 124A/G gene polymorphisms were investigated by the restriction fragment length polymorphism polymerase chain reaction. Results: For FAS gene, G/G genotype was significantly higher in cases than in control group with odds ratio 5.1. G allele was more prevalent among patient group with odds ratio 1.75. For FASL gene, A/G genotype was significantly higher in cases than in control group with odds ratio 4.53. G allele was more prevalent among patient group with odds ratio 1.88. GG genotype of FAS was significantly associated with longer disease duration (P=0.001), recurrent attacks (P=0.01), higher SALT score (P=0.009), alopecia universalis (P=0.002), and severe disease (P=0.006). Conclusion: FAS and FASL gene polymorphisms are associated with AA. Further large-scale studies on different ethnicities are required for more clarification of their role in disease development. Therapeutic modalities based on their inhibition could be promising in the treatment of a common disease like AA.
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Serum zinc level in vitiligo: A case-control study Highly accessed article p. 227
Mina Mirnezami, Hoda Rahimi
Background: Vitiligo is characterized by the idiopathic destruction of melanocytes, probably of autoimmune etiology, that results in depigmented patches of skin and mucosal surfaces. Oxidative stress may contribute to the pathogenesis of vitiligo. Zinc, a trace element with antiapoptotic properties, plays a major role in the process of melanogenesis and elimination of free radicals. The present study was conducted with the aim of comparing serum zinc levels in patients with vitiligo and in normal controls. Materials and Methods: In this case–control study, we studied 103 patients with vitiligo and 103 healthy sex-and age-matched controls. Serum zinc levels were measured in these two groups using atomic absorption spectrophotometry and compared with each other. Results: The mean serum zinc level was 92.1 mcg/dl in the focal vitiligo, 81.3 mcg/dl in the generalized vitiligo, and 91.8 mcg/dl in the control group. A significant difference in serum zinc levels was observed between the patients with generalized vitiligo and the controls. Lower serum zinc levels were also correlated with longer duration of the disease. Furthermore, a negative relationship was found between serum zinc level and age of patients with vitiligo. Conclusion: Serum zinc level is low in patients with generalized vitiligo. In these patients, serum zinc level is in negative correlation with patient's age and disease duration.
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Re-appraisal of keratinocytes' role in vitiligo pathogenesis p. 231
Ola Ahmed Bakry, Mohamed Abd El Moneim Shoeib, Noha El Kady, Shereen Attalla
Background: Vitiligo is a common pigmentary disorder. Studies on its pathogenesis extensively investigated melanocytes' abnormalities and few studies searched for keratinocytes' role in disease development. Liver X receptor-α (LXR-α) is a member of nuclear hormone receptors that acts as a transcription factor. Its target genes are the main regulators of melanocyte functions. Aim: The aim of this study is to investigate keratinocytes' role in vitiligo pathogenesis through immunohistochemical expression of LXR-α in lesional, perilesional, and distant nonlesional vitiligo skin. Materials and Methods: This case–control study was carried out on 44 participants. These included 24 patients with vitiligo and 20 age- and sex-matched normal individuals as a control group. Biopsies, from cases, were taken from lesional, perilesional, and distant nonlesional areas. Evaluation was done using immunohistochemical technique. Results: Keratinocyte LXR-α expression was upregulated in the lesional and perilesional skin (follicular and interfollicular epidermis) compared with control skin (P<0.001 for all). There was significant association between higher histoscore (H-score) in lesional epidermis (P<0.001) and in hair follicle (P=0.001) and the presence of angiogenesis. There was significant association between higher H-score in lesional epidermis and suprabasal vacuolization (P=0.02). No significant association was found between H-score or expression percentage and clinical data of selected cases. Conclusion: LXR-α upregulation is associated with keratinocyte damage in vitiligo lesional skin that leads to decreased keratinocyte-derived mediators and growth factors supporting the growth and/or melanization of surrounding melanocytes. Therefore, melanocyte function and survival are affected.
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Do prolactin and its receptor play a role in alopecia areata? p. 241
Samar M El Tahlawi, Nermeen H El Eishi, Rima K Kahhal, Rehab A Hegazy, Ghada M El Hanafy, Rania M Abdel Hay, Olfat G Shaker
Context: Studying the link between prolactin and autoimmunity has gained much ground over the past years. Its role played in alopecia areata (AA) is not clear yet, as previous reports yielded controversial results. Aims: This study aimed to measure the serum level of prolactin and to detect the expression of its receptor in AA, in an attempt to highlight its possible role in the pathogenesis of this disease. Subjects and Methods: A case-control study of 30 AA patients and 20 controls from outpatient clinic were undertaken. Every patient was subjected to history taking and clinical examination to determine the severity of alopecia tool (SALT) score. Blood samples were taken from patients and controls to determine the serum prolactin level. Scalp biopsies were obtained from the lesional skin of patients and normal skin of controls for assessment of the prolactin receptor. Statistical Analysis: Depending upon the type of data, t-test, analysis of variance test, Chi-square, receiver operator characteristic curve were undertaken. Results: On comparing the serum prolactin level between patients and controls, no significant difference was found, while the mean tissue level of prolactin receptor was significantly higher in patients than in controls. In patients, a significant positive correlation was found between the prolactin receptor and the SALT score. Conclusions: Prolactin plays a role in AA, and this role is probably through the prolactin receptors rather than the serum prolactin level.
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Assessment of heavy metal and trace element levels in patients with telogen effluvium p. 246
Ibrahim Halil Yavuz, Goknur Ozaydın Yavuz, Serap Gunes Bilgili, Halit Demir, Canan Demir
Background: Despite a multitude of studies, etiology of primary chronic telogen effluvium (TE) remains incompletely understood. Essential heavy metals are associated with beneficial effects in humans as well as in other living organisms. However, they may lead to toxic effects when the exposure exceeds the higher tolerable limits. We wanted to assess the heavy metal and trace element levels in patients with chronic TE. Materials and Methods: A total of 40 subjects with chronic TE were included in the study, and 30 healthy women served as control. General and dermatological examinations were taken up in all individuals. Those patients with positive hair pull test were evaluated with the help of a trichogram. The presence of >20% telogen hair as documented by trichogram was a requirement for the study inclusion. UNICAM-929 spectrophotometry device was used for determining serum trace element and heavy metal concentrations. Results: In spite of an absence of significant differences in terms of average Zn concentration, weight, or height between patients and controls, significant differences were noted for Cd, Fe, Mg, Mn, Pb, Co, and Cu (P<0.05). Conclusion: Our results suggest that heavy metals may play a causative role in the development of chronic TE. However, contrary to previous reports, zinc did not appear to play an important etiological role, while these patients had elevated serum iron levels.
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Retinol levels in serum and chronic skin lesions of atopic dermatitis p. 251
Rabindranath Biswas, Goutam Chakraborti, Kheya Mukherjee, Debojyoti Bhattacharjee, Sabyasachi Mallick, Tanmoy Biswas
Background: Atopic dermatitis (AD) is a common childhood dermatosis and a distressing cause of morbidity. The pathogenesis of AD is known to be associated with disorders of immune response and defect in antioxidant defense, genetic predisposition, environmental triggers, psychosomatic factors, and other mechanisms. Retinol has immunomodulatory and antioxidant effects, thus may have a protective role in AD. Objective: The objective of this study was to evaluate the correlation of retinol levels in skin lesions and serum, with AD. Materials and Methods: The study was a hospital-based, case–control study. Punch biopsy from the skin and venous blood of 86 participants (including 43 cases and 43 controls) were assayed for retinol levels by a reversed-phase high-performance liquid chromatography method. Analysis of data was performed using appropriate statistical methods. Results: Skin and serum retinol levels were highly significantly decreased in patients in respect to that of controls. Conclusion: Retinol levels were decreased in AD. Retinol estimation may be used as a promising parameter for the elaboration of treatment strategy and monitoring.
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Low Vitamin D in psoriasis: Reality or myth? p. 255
Preethi B Nayak, Banavasi Shanmukha Girisha, Tonita Mariola Noronha, Handattu Sripathi
Context: Psoriasis is a chronic, systemic disease with the beneficial effect of topical vitamin D3 analogs, known for a long time. Low levels of vitamin D are increasingly found to be associated with the initial development of some autoimmune diseases. There are contradictory reports of low serum levels of vitamin D3 in the pathogenesis of psoriasis. Aims: (1) To determine the serum levels of vitamin D, calcium and C-reactive protein (CRP) in patients with psoriasis vulgaris, (2) To compare these levels with the serum levels of controls, and (3) To correlate them with the severity of the disease. Subjects and Methods: A hospital-based case–control study with 61 patients of psoriasis and 61 age- and sex-matched controls was undertaken. A detailed history was taken and examination including body mass index, Psoriasis Area and Severity Index (PASI) was done. Estimations of serum vitamin D, serum calcium, and CRP levels were done. Results: Mean 25(OH) vitamin D level was not significantly different between persons with and without psoriasis. Mean vitamin D level in cases was 18.41±9.41 and that in controls was 17.24±13.03 (P=0.63). However, vitamin D level were significantly lower in females than in males in both cases (P=0.02) and controls (P=0.006). There was no significant correlation between the severity of psoriasis and serum levels of vitamin D, serum calcium, and CRP. Conclusions: Serum level of vitamin D did not correlate with the severity of psoriasis in our study.
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Reed's syndrome p. 261
Filipa Tavares Almeida, Rui P Santos, Sofia D Carvalho, Maria C Brito
Multiple cutaneous and uterine leiomyomatosis (MCUL), also known as Reed's syndrome, is a rare genodermatosis, with an autosomal dominant pattern of inheritance. It results from a germline heterozygous mutation of fumarate hydratase gene, that is classified as a tumor suppressor gene. Hereditary leiomyomatosis and renal cell cancer is characterized by the association of MCUL with renal cell carcinoma. We report a case of a 57-year-old woman, with multiple cutaneous leiomyomas as the presenting sign of Reed's syndrome.
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Interstitial granulomatous dermatitis due to a rare myeloproliferative neoplasia p. 264
Sandra Cases-Merida, Ana Lorente-Lavirgen, Amalia Pérez-Gil
Interstitial granulomatous dermatitis (IGD) was first described in 1993 by Ackerman as a cutaneous reactive disease in patients with arthritis. Since then, numerous cases associated with different hematological and rheumatic disorders have been reported. IGD is a polymorphic entity that usually involves the upper part of the trunk. Histologically, it is defined as a diffuse dermal histiocytic infiltrate of different densities surrounded by fragmented collagen. We report the case of a 56-year-old man with pruritic papules affecting neck, proximal arms and thorax associated with weight loss and chronic fatigue for six months. Two punch biopsies were taken and the specimens showed lymphohistiocytic interstitial infiltrates with fragmented collagen and elastic fibers in dermis. IGD was diagnosed as first manifestation of a rare chronic myeloproliferative hematologic disorder (cMPD) with rearrangement of beta-receptor for platelet-derived growth factor (PDGFRB). After two months of imatinib, lesions regressed completely.
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ANCA-associated vasculitis in a case of congenital leptin deficiency p. 268
Atiya Yaseen, Shagufta Rather, Faizan Yunus, Iffat Hassan
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Systemic retinoids and thyrotoxicosis in (Multi) nodular goiter: Side effect or coincidence? p. 270
Berna Aksoy
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Onychomadesis: A rare skin sign occurring after chickenpox p. 272
Andrea Sechi, Marco Adriano Chessa, Miriam Leuzzi, Iria Neri
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Albendazole induced easy bruising in a patient of hydatid cyst of liver p. 273
Jyoti Budhwar, Chetna Singla, Bharat Bhushan Mahajan
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Subcutaneous left cervical nodule in an infant present since birth p. 275
Jyotsna Naresh Bharti, Biswajit Dey, Jitendra Singh Nigam, Ashok Singh
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Annular and linear brown patches in axillae p. 277
Alba Gómez-Zubiaur, Laura Pericet-Fernández, María Dolores Vélez-Velázquez, Lidia Trasobares-Marugán
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