Indian Journal of Dermatology
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   Table of Contents - Current issue
Coverpage
November-December 2019
Volume 64 | Issue 6
Page Nos. 423-509

Online since Thursday, November 7, 2019

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CME ARTICLE  

Ocular side effects of systemic drugs used in dermatology Highly accessed article p. 423
Bhanu Prakash, H Mohan Kumar, Saranya Palaniswami, Borra Harish Lakshman
DOI:10.4103/ijd.IJD_353_18  
Some systemically used drugs in managing dermatologic disorders have associated severe side effects, of which eye involvement is very significant. There are various mechanisms for these drugs to cause damage to the eye. The damage to the eye can be acute as in Stevens–Johnson syndrome or chronic as with chloroquine and hydroxychloroquine toxicity. Knowledge about these drugs and information about the mechanisms and types of damage to the eye are essential. It is also important to understand the monitoring mechanisms to diagnose early and limit the damage. Newer investigative tools, especially the imaging techniques help us to diagnose the adverse effects at an early stage. All these issues are discussed in brief here.
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BASIC RESEARCH Top

Evaluation of lymphocyte migration to induced paederus dermatitis: An experimental study in rats Highly accessed article p. 431
Fereshteh Hosseini Valiki, Mohammad Mahdi Mohammadi, Abolghasem Ajami, Alireza Khalatbari, Farzad Motevalli Haghi
DOI:10.4103/ijd.IJD_447_18  
Background: Paederus dermatitis (PD) is a blistering disorder that is caused by a small insect of the genus Paederus, especially Paederus fuscipes. This study aimed to investigate the reaction of the adaptive immune system regarding the recruitment of CD3, CCR4, and CCR10 markers, which are specifically expressed on the surface of T lymphocytes. Materials and Methods: In this experimental study, 24 female rats were divided into two groups: the test and the negative control. In the test group, PD was induced by making insects in contact with shaved rat skin. Biopsies were obtained 24, 72, and 120 h after induction. In the negative control group, physiological saline was applied. Specimens were evaluated by immunohistochemical staining method. Antibodies against CD3, CCR4, and CCR10 were used. Distribution and staining intensities of CD3, CCR4, and CCR10 markers were estimated by the H-score index and findings were analyzed using the Kruskal–Wallis and Wilcoxon statistical tests. Results: Based on the results of immunohistochemistry, the expression of CD3, CCR4, and CCR10 in the test group at 24, 72, and 120 h compared to the control group showed significant increase (P = 0.0006, P = 0.001, and P < 0.0001), respectively. The peak of expression of all markers was at 72 h after exposure. Hematoxylin and eosin staining also confirmed the fact that the majority of the lymphocyte infiltration occurred at 72 h postexposure. Conclusion: The expression of CD3, CCR4, and CCR10 on cells present in PD lesions could indicate that T-lymphocytes are recruited to the site of inflammation by chemokine–chemokine receptor interactions and hence provide evidence for the response by the adaptive immune system following a PD.
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ORIGINAL ARTICLES Top

Extracellular matrix protein 1 gene mutation in turkish patients with lipoid proteinosis p. 436
Selma Bakar Dertlioğlu, Tuba Gökdoğan Edgünlü, Deniz Erol Şen, Tugba Önal Süzek
DOI:10.4103/ijd.IJD_365_18  
Background: Lipoid proteinosis (LP) is a rare autosomal recessive genodermatosis characterized by mucocutaneous lesions and hoarseness of voice that develop in early childhood. LP is caused by mutation in the extracellular matrix protein 1 (ECM1) gene, which is located on 1q21.2. Aims: This study aimed to present the profile of ECM1 gene mutations and to identify possible novel mutations specific to Turkey. Materials and Methods: The ECM1 gene mutations of 19 LP patients from five families were evaluated using DNA isolated from peripheral blood samples. All ten exons in the ECM1 gene region were amplified by polymerase chain reaction (PCR). The PCR products were analyzed using a DNA sequencing analyzer. The results of DNA sequencing were analyzed with bioinformatics methods. Results: of the 19 LP patients evaluated in our study, we detected defects in exon 6 (c.507delT, 658T>G), exon 9 (157C>T, 727C>T), and exon 10 (c.93_94delGCinsTT) of the ECM1 gene. Conclusions: Our results indicate that defects in exons 6, 9, and 10 of the ECM1 gene were responsible for LP in our country. The identification of these pathogenic mutations is valuable because it facilitates early diagnosis and genetic counseling.
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Increased plasma levels of S100A8, S100A9, and S100A12 in chronic spontaneous urticaria p. 441
Qiong-Yan Zhou, Wei Lin, Xiao-Xia Zhu, Su-Ling Xu, Meng-Xia Ying, Lei Shi, Bing-Jiang Lin
DOI:10.4103/ijd.IJD_375_18  
Background: Chronic spontaneous urticaria (CSU) is a skin disorder with an important immunologic profile. S100A8, S100A9, and S100A12 are the members of S100 family that have been reported to play important role in autoimmune diseases, but the characteristics of these three S100 members have not been defined in CSU. Aims: This study was performed to investigate the levels of these three S100s in patients with CSU and to study whether they were associated with the severity and clinical characteristics of CSU. Materials and Methods: The levels of plasma S100A8, S100A9, and S100A12 were measured in 51 CSU patients and 20 healthy controls using enzyme linked immunosorbent assay kits. The values in the patient group and that of the healthy controls were statistically compared. The relationships between the different markers were evaluated by correlation analysis. Results: The plasma levels of S100A8, S100A9, and S100A12 were significantly higher in CSU patients than those in controls. Interestingly, the level of S100A12 was significantly correlated with S100A8 and S100A9 in CSU patients (P < 0.05 and P < 0.001, respectively). In addition, S100A8, S100A9, and S100A12 were all significantly inversely correlated with blood basophil percentage. Conclusions: Plasma S100A8, S100A9, and S100A12 levels were elevated in CSU patients. They might be useful biomarkers of CSU, with the potential role in the pathogenesis of CSU.
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Evaluation of neopterin level and disease severity in patients with psoriasis vulgaris treated with narrowband UVB p. 447
Funda Kemeriz, Müzeyyen Gönül, Fatma Pelin Cengiz, Nazan Emiroğlu, Bengü Çevirğen Cemil
DOI:10.4103/ijd.IJD_53_18  
Background: Neopterin is a biochemical marker of cellular immunity. It has been reported that serum and urine neopterin levels increase in psoriasis and decrease with treatment. Nevertheless, assessment of a direct link between narrowband ultraviolet B (UVB) therapy and neopterin level in association with Psoriasis Area and Severity Index (PASI) scores has not been performed yet. We aimed to evaluate the serum neopterin level in patients with psoriasis treated with narrowband UVB therapy in association with disease severity. Materials and Methods: The study included 35 patients with chronic plaque-type psoriasis who had PASI scores of >10 or below 10 but resistant to topical therapies and 30 healthy individuals. The narrowband UVB therapy was administered to the patient group (n = 35). Serum neopterin analysis was performed with an enzyme-linked immunosorbent assay method before and after treatment. Results: There was statistically significant correlation between neopterin level and PASI score in the patient group (P = 0.011). The serum neopterin level was significantly increased in patients with higher PASI score. Moreover, the serum neopterin level was found to be statistically higher in severe psoriasis group (PASI score ≥10, n = 14) than the mild-moderate group (PASI score <10, n = 21) (P = 0.001). Furthermore, a significant decrease was observed according to serum neopterin level after the narrowband UVB therapy in the remaining 20 patients who were able to comply with the scheduled therapy and follow-up procedure (P = 0.026). Conclusion: Serum neopterin levels were found to be an useful marker for evaluating disease severity and efficacy of narrowband UVB treatment. Thus, our findings may provide a new approach with the management of disease and follow-up strategies in patients with psoriasis.
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The association between attention-deficit/hyperactivity disorder and Atopic dermatitis: A study among Iranian children p. 451
Najmolsadat Atefi, Masoumeh Rohaninasab, Mitra Shooshtari, Elham Behrangi, Golnaz Mehran, Azade Goodarzi, Sadaf Sajedi Moghadam, Safoura Shakoei
DOI:10.4103/ijd.IJD_458_18  
Background: The co-occurrence of attention-deficit/hyperactivity disorder (ADHD) with atopic dermatitis (AD) has been well described in some recent association studies; however, we did not have any perspective on this relationship in our country. Aim and Objective: Hence, the present study aimed to assess the prevalence of ADHD in children with AD. Materials and Methods: This cross-sectional study was performed on 95 consecutive children and adolescents (aged 4–18 years) who were referred to dermatology clinics at the two hospitals in Tehran during 2017 with atopic dermatitis. The evidence of atopy was assessed using the 2003 National Survey of Children's Health. The diagnosis of ADHD was based on the Conner Rating Scale. The sleep disorder was also assessed by the Pittsburg sleep quality questionnaire. Results: The prevalence of hyperactivity and attention deficit in our AD patients was 20.0% and 29.47%, respectively. Furthermore, patients with sleep problem were significantly more likely to have hyperactivity disorder (odds ratio [OR]: 2.91, 95% confidence interval [CI]: 1.04–8.16, P = 0.04). According to the results of multiple logistic regression analyses, flexor involvement was the only predictor of hyperactivity disorder in the final model. The univariate and multivariate analyses showed that having attention deficit was associated with having cheek involvement (OR = 3.63, 95% CI: 1.44–9.14, P = 0.01) and sleep problem (OR = 3.68, 95% CI: 1.45–9.33, P = 0.01). Conclusion: It seems that neurocognitive disturbances due to sleep restriction in AD children may be one of the main trigger, especially for attention deficit.
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Role of vascular ultrasound in cases of lower limb hyperpigmentation p. 456
Himanshu Kumar, PK Sharma, UC Garga
DOI:10.4103/ijd.IJD_393_18  
Background: Hyperpigmentation remains an important finding in cases of venous insufficiency and peripheral arterial disease (PAD) among the vascular causes. Aims: This study aimed at finding the presence of arterial and/or venous insufficiency in patients of lower leg hyperpigmentation by using vascular ultrasound (US). Materials and Methods: Fifty patients of lower leg pigmentation were included in the study. The detailed history, general physical examination, and laboratory investigations were done. Color Doppler ultrasonography was performed to check for venous insufficiency/PADs. Qualitative variables were correlated using chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. Results: The mean age of the patients was 44.32 ± 14.16 years. Four patterns of skin changes were seen - reticulate macular, diffuse macular, lipodermatosclerosis and ulcer. Thirty-five (70%) patients had no visible varicose vein while 15 (30%) had visible varicose vein. In patients with visible varicose vein, color Doppler showed signs of venous insufficiency in all patients, but in cases of no visible varicose vein, color Doppler showed signs of venous insufficiency in 19 (54.28%) patients and showed no signs of venous insufficiency in others (P = 0.78). Only 1 (2%) patient showed atherosclerotic changes in both anterior tibial arteries. Conclusion: All patients with lower leg pigmentation with or without visible varicose vein should undergo vascular US to rule out any venous insufficiency.
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Contact dermatitis due to local cosmetics: A study from Northern India p. 461
Sheena Goyal, Naheed Sajid, Sajid Husain
DOI:10.4103/ijd.IJD_479_19  
Background: Majority of the cosmetics are synthetic in nature and capable of causing dermatitis among frequent users. Some cosmetics (bindi, sindoor, etc.) that cause serious skin inflammation are specific to Indian culture. Aim: To study the prevalence of contact dermatitis due to various cosmetics indigenous among Indian users. Materials and Methods: A cross-sectional study of 2,150 patients who attended dermatitis clinic at a regional hospital in north India. A total of 400 of these were suspected of cosmetic dermatitis based on clinical grounds and were subjected to patch test using Indian Standard Series and Cosmetic series kit. Results: Among the 400 patients identified for cosmetic dermatitis, 352 (88%) were female and 326 (81.5%) between 20 and 49 years of age. Bindi/kumkum (30%), hair dye (18%), and deodorant/perfume (14%) were primary cosmetics causing contact dermatitis. Patch test with the suspected cosmetics was positive in 52.75% cases. Patients who visited their doctor in the early stages of appearance of symptoms (<3 months) were more likely to have positive patch test. Conclusion: Higher incidence of cosmetic dermatitis is observed in adult females aggravated by use of inferior quality cosmetics. Early detection of the disease can be helpful.
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Effect of topical steroid-dependent facial dermatitis on quality of life: A hospital-based cross-sectional study using DLQI p. 465
Madhur K Rastogi, Rikta Mohan, Pratik Gahalaut, Nitin Mishra, Manisha Thapa
DOI:10.4103/ijd.IJD_176_18  
Background: The rampant, disturbing, and dismal unrestricted use of topical corticosteroids on face results in steroid-induced dermatitis termed topical steroid-dependent face (TSDF). It is an embarrassing and irritating condition for a patient. There is paucity of data from India regarding the effect of TSDF on the quality of life (QoL) of such patients. Aims: The aim of this study was to study the effect of TSDF on the QoL of patients with the help of a validated, easy-to-use, and reproducible dermatology life quality index (DLQI). Methods: A cross-sectional study was done among the outpatients seeking treatment for TSDF at a tertiary care hospital of a medical college. Patients were administered Hindi questionnaire version of DLQI. Controls were apparently healthy age- and sex-matched individuals. Results: DLQI scores revealed that TSDF had some effect on QoL in 98.11% of study patients. Study group had a mean DLQI score of 11.49. Statistically significant higher DLQI scores were recorded among females, patients aged <20 years and those who had no formal education/illiterate. Conclusions: TSDF affects QoL in majority of patients and it has a very large effect on the QoL in more than one-third of the patients.
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Cutaneous adverse drug reactions to targeted chemotherapeutic drugs: A clinico-epidemiological study p. 471
Kriteeka Saini, Amita Sutaria, Bela Shah, Vinita Brahmbhatt, Kirti Parmar
DOI:10.4103/ijd.IJD_491_18  
Background: Targeted chemotherapeutic drugs have led to a remarkable improvement in the survival of cancer patients but also have resulted in the increased incidence of uncommon but specific muco-cutaneous adverse effects. Aims: This study aimed to highlight the spectrum of such cutaneous adverse drug reactions and to derive a causal association. Materials and Methods: A hospital-based, descriptive study was carried out in the dermatology outpatient department between August 2016 and July 2018, on patients referred from the state cancer institute, who developed muco-cutaneous lesions after the initiation of targeted chemotherapeutic drugs. Results: A total of 80 patients, 59 (74%) males and 21 (26%) females of mean age 45.83 ± 16.37 years (range 4–70 years) developed one or more uncommon albeit specific muco-cutaneous adverse effects. Among them, papulopustular and acneiform eruptions were found in 21 patients (26.25%), and PRIDE complex was seen in 3 patients. Sixteen patients (20.00%) developed palmar-plantar erythrodysesthesia, 8 patients (10%) developed lichenoid drug eruption, and 5 patients (6.25%) developed flagellate dermatitis. Twenty-two (27.5%) patients showed nail changes, the most common, being melanonychia. Conclusion: There has been a paradigm shift in the management of both hematopoietic and solid cancers with the advent of targeted chemotherapeutic drugs leading to an increase in uncommon and specific drug reactions. Early recognition of these decreases morbidity, improves quality of life, and allows continuation of the life saving chemotherapy.
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Onychomycosis unresponsive to antifungals: Etiology and treatment with a new direct technique p. 476
Fatma Gülru Erdogan, Dilsun Yıldırım, Gül Aslıhan Çakır Akay
DOI:10.4103/ijd.IJD_453_18  
Aims and Objectives: The aim of this study was to identify the fungal agents causing onychomycosis that were unresponsive to antifungal treatment and to treat these cases by placing under-nail cushions with a mild keratolytic to clear the fungus-invaded tissue. Materials and Methods: Fungal agents were identified by the matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) technique. Results: Nine patients had Aspergillus spp. (7 Aspergillus niger,2 Aspergillus flavus); four had Candida species and one had Trichophyton rubrum. All patients were free of infection at the end of treatment. Conclusion: As per the results, we may state that onychomycosis that is unresponsive to treatment in immunocompetent patients seems to be mostly associated with molds. Direct application of a mild keratolytic to the fungus-invaded part, e.g., the nail plate and/or nail bed and removal of fungal elements may provide a successful treatment outcome.
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CASE REPORTS Top

A case series of pseudoxanthoma elasticum-like disorders p. 482
Sarah Bandar Aljoudi, Mohammed Haithm Abduljabbar, Jehad Osama Hariri
DOI:10.4103/ijd.IJD_89_18  
Pseudoxanthoma elasticum (PXE)-like papillary dermal elastolysis and focal dermal elastosis are acquired noninflammatory elastic tissue disorders. The skin lesions clinically resemble PXE without systemic involvement. We report the clinicopathological features of five cases and discuss the pathogenesis and differential diagnosis. Increased awareness of this newly described entity will broaden the differential diagnosis for dermatologists when encountering a similar case scenario.
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An uncommon coexistence of sarcoidosis and cutaneous leukocytoclastic vasculitis in an adult p. 486
Birsen Ocakli, Ipek Özmen, Esin Sonkaya, Lale Sertçelik, Sibel Boga, Hatice Türker, Özer Ocakli, Sirin Yasar, Pembegül Binbir Günes, Ayçim Sen, Zuhal Karakurt
DOI:10.4103/ijd.IJD_291_18  
The skin is the second most commonly involved organ after pulmonary system in sarcoidosis, a multisystemic granulomatous disease. Cutaneous small-vessel vasculitis (leukocytoclastic vasculitis [LCV]) is a disorder characterized by neutrophilic inflammation of small blood vessels. Although the skin is the organ where LCV is seen most frequently, extracutaneous involvements are also seen. Herein, we present a coexistence of sarcoidosis and cutaneous LCV, which is an uncommon condition in adult.
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Congenital giant folliculosebaceous cystic hamartoma of thigh: A rare case p. 490
Vedita Madhukar Bobde, Satish B Helwatkar, Prajakta R Sathawane, WK Raut
DOI:10.4103/ijd.IJD_319_18  
Hamartomatous conditions of skin are comprised of variable composition of normal skin elements. They can present as nodular masses. They can be mistaken for neoplastic skin lesions. Folliculosebaceous cystic hamartoma is a rare skin condition seen in adults, commonly on head, neck and face region. Congenital variant is rare. Only few case reports have been described in literature occurring on sites other than face. Definitive diagnosis can be given only on histopathology. We report a case presenting as thigh mass in a 1 year old female child clinically diagnosed as papilloma of skin.
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Hydroa vacciniforme-like lymphoma with systemic symptoms: Two case reports p. 493
Litao Wang, Yuwen Su, Jianzhong Zhang, Haiquan Wen, Guiying Zhang
DOI:10.4103/ijd.IJD_178_18  
Two Chinese children presented with relapsing papules, vesicles, ulcers on the face and limbs with systemic symptoms being caused by mosquito bite. Lesion biopsy revealed atypical lymphocyte in the dermis and subcutis. Immunohistochemistry identified cells as positive for CD3, CD45RO, TIA-1 and EBER. Taken together, both the patients were diagnosed with hydroa vacciniforme-like lymphoma. Two patients showed significant improvement in clinical symptoms after being treated with acyclovir, low dose predisone and IFN-α.
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CORRESPONDENCES Top

Cauliflower ear: A rare manifestation of phaeohyphomycosis p. 497
C Chandrakala, Gurusami K Tharini
DOI:10.4103/ijd.IJD_101_18  
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Anterior scleritis in a patient of pemphigus vulgaris while on immunosuppressive treatment p. 499
Mihika Dube, Brijesh Takkar, Dinesh P Asati, Sourabh Jain
DOI:10.4103/ijd.IJD_318_18  
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Pachydermoperiostosis Associated with Myelofibrosis: A Rare Case Report p. 501
Pedro Secchin, Nurimar C Fernandes, Danielle C Quintella, Juliano A R Silva, Juliana Medrado, Taissa C Magalhães
DOI:10.4103/ijd.IJD_360_18  
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Total anonychia, spastic diplegia, and mental retardation in an Indian boy: A novel syndrome? p. 504
Vibhu Mendiratta, Anuja Yadav
DOI:10.4103/ijd.IJD_532_18  
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Blue toe syndrome: A challenging diagnosis p. 506
Federico Tartari, Ambra Di Altobrando, Yuri Merli, Annalisa Patrizi, Michele Mirelli, Tommaso Bianchi
DOI:10.4103/ijd.IJD_580_18  
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Multivitamins as a culprit of fixed drug eruption p. 508
Parul Verma, Pramila Kumari, Swastika Suvirya
DOI:10.4103/ijd.IJD_601_18  
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