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Indian Journal of Dermatology
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   Table of Contents - Current issue
Coverpage
May-June 2017
Volume 62 | Issue 3
Page Nos. 227-327

Online since Friday, May 12, 2017

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EDITORIAL  

The great Indian epidemic of superficial dermatophytosis: An appraisal Highly accessed article p. 227
Shyam Verma, R Madhu
DOI:10.4103/ijd.IJD_206_17  
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REVIEW ARTICLE Top

Use of topical corticosteroids in dermatology: An evidence-based approach p. 237
Anupam Das, Saumya Panda
DOI:10.4103/ijd.IJD_169_17  
Topical corticosteroids (TCs) are the pillars of dermatotherapeutics. These drugs are the “magic molecules,” provided they are used judiciously and appropriately, following a rational prescription. On exhaustive literature search in multiple databases, we found a significant evidence favoring the use of TCs in atopic eczema, localized vitiligo, psoriasis, chronic hand eczema, and localized bullous pemphigoid. However, contrary to conventional wisdom, we did not find any high-level scientific evidence in support of prescribing TCs in cutaneous lichen planus, sarcoidosis, and seborrhoeic dermatitis. Besides, evidence clearly advocates judicious use of mild-to-moderate corticosteroids (if required) in pregnancy and lactation and there is no risk of any fetal abnormality.
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IJD MODULE ON BIOSTATISTICS AND RESEARCH METHODOLOGY FOR THE DERMATOLOGIST - MODULE EDITOR: SAUMYA PANDA Top

Biostatistics series module 9: Survival analysis p. 251
Avijit Hazra, Nithya Gogtay
DOI:10.4103/ijd.IJD_201_17  
Survival analysis is concerned with “time to event“ data. Conventionally, it dealt with cancer death as the event in question, but it can handle any event occurring over a time frame, and this need not be always adverse in nature. When the outcome of a study is the time to an event, it is often not possible to wait until the event in question has happened to all the subjects, for example, until all are dead. In addition, subjects may leave the study prematurely. Such situations lead to what is called censored observations as complete information is not available for these subjects. The data set is thus an assemblage of times to the event in question and times after which no more information on the individual is available. Survival analysis methods are the only techniques capable of handling censored observations without treating them as missing data. They also make no assumption regarding normal distribution of time to event data. Descriptive methods for exploring survival times in a sample include life table and Kaplan–Meier techniques as well as various kinds of distribution fitting as advanced modeling techniques. The Kaplan–Meier cumulative survival probability over time plot has become the signature plot for biomedical survival analysis. Several techniques are available for comparing the survival experience in two or more groups – the log-rank test is popularly used. This test can also be used to produce an odds ratio as an estimate of risk of the event in the test group; this is called hazard ratio (HR). Limitations of the traditional log-rank test have led to various modifications and enhancements. Finally, survival analysis offers different regression models for estimating the impact of multiple predictors on survival. Cox's proportional hazard model is the most general of the regression methods that allows the hazard function to be modeled on a set of explanatory variables without making restrictive assumptions concerning the nature or shape of the underlying survival distribution. It can accommodate any number of covariates, whether they are categorical or continuous. Like the adjusted odds ratios in logistic regression, this multivariate technique produces adjusted HRs for individual factors that may modify survival.
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Methodology series module 9: Designing questionnaires and clinical record forms – Part II p. 258
Maninder Singh Setia
DOI:10.4103/ijd.IJD_200_17  
This article is a continuation of the previous module on designing questionnaires and clinical record form in which we have discussed some basic points about designing the questionnaire and clinical record forms. In this section, we will discuss the reliability and validity of questionnaires. The different types of validity are face validity, content validity, criterion validity, and construct validity. The different types of reliability are test-retest reliability, inter-rater reliability, and intra-rater reliability. Some of these parameters are assessed by subject area experts. However, statistical tests should be used for evaluation of other parameters. Once the questionnaire has been designed, the researcher should pilot test the questionnaire. The items in the questionnaire should be changed based on the feedback from the pilot study participants and the researcher's experience. After the basic structure of the questionnaire has been finalized, the researcher should assess the validity and reliability of the questionnaire or the scale. If an existing standard questionnaire is translated in the local language, the researcher should assess the reliability and validity of the translated questionnaire, and these values should be presented in the manuscript. The decision to use a self- or interviewer-administered, paper- or computer-based questionnaire depends on the nature of the questions, literacy levels of the target population, and resources.
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IJD SYMPOSIUM Top

Pathophysiology of autoimmune bullous diseases: Nature versus nurture Highly accessed article p. 262
Forum Patel, Reason Wilken, Falin B Patel, Hawa Sultani, Itzel Bustos, Christopher Duong, John J Zone, Siba P Raychaudhuri, Emanual Maverakis
DOI:10.4103/0019-5154.159620  
Pemphigus and pemphigoid are the prototypical immunobullous diseases. Although it has been well established that they are caused by deposition of autoreactive antibodies directed against adherence proteins within the skin, the specific genetic and environmental factors leading to development of these diseases continue to be an area of investigation. Herein, we discuss several of the potential environmental triggers that may induce patients to develop immunobullous diseases including medications, viral infections, UV exposure or other radiation injury and dietary factors. In addition, the potential genetic and immunologic mechanisms contributing to the pathogenesis of pemphigus and pemphigoid will be reviewed. The multifactorial nature of these diseases contributes to their complexity and highlights the importance of a detailed personal and family history when caring for these patients.
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Advanced diagnostic techniques in autoimmune bullous diseases p. 268
Anuradha Jindal, Raghavendra Rao, Balbir S Bhogal
DOI:10.4103/ijd.IJD_196_17  
Autoimmune blistering diseases are diverse group of conditions characterized by blisters in the skin with or without mucosal lesions. There may be great degree of clinical and histopathological overlap; hence, advanced immunological tests may be necessary for more precise diagnosis of these conditions. Direct immunofluorescence microscopy is the gold standard tests to demonstrate the tissue-bound antibodies and should be done in all cases. Magnitude of antibody level in patient' serum can be assessed by indirect immunofluorescence and enzyme linked immunosorbent assay. In this article we have reviewed the various techniques that are available in the diagnosis of autoimmune blistering diseases.
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Counseling in pemphigus p. 279
Raghavendra Rao, CR Srinivas
DOI:10.4103/ijd.IJD_198_17  
Pemphigus is a chronic, potentially life threatening, autoimmune intraepidermal blistering disease affecting the skin and the mucous membrane. Pemphigus may have profound impact on the quality of life in the affected patients. Counselling and adjuvant psychotherapy may be beneficial at least in few patients and should be considered as a part of multidisciplinary approach.
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Shifting focus in the therapeutics of immunobullous disease p. 282
Abhishek De, Asad Ansari, Nidhi Sharma, Aarti Sarda
DOI:10.4103/ijd.IJD_199_17  
Therapeutics of autoimmune bullous disease has seen a major shift of focus from more global immunosuppression to targeted immunotherapy. Anti CD 20 monoclonal antibody Rituximab revolutionized the therapeutics of autoimmune bullous disease particularly pemphigus. Though it is still being practiced off-label, evidences in the form of RCT and meta analysis are now available. Other novel anti CD 20 monoclonal antibodies like ofatumumab, veltuzumab, and ocrelizumab, tositumomab or obinutuzumab/GA101 may add to the therapeutic options in coming days. Beyond anti CD 20 monoclonal antibodies other options that show promise at least in select scenario are omalizumab, TNF inhibitors plasmapheresis and intravenous immunoglobulin. The present article will discuss the role of rituximab and other newer therapeutics in the treatment of autoimmune blistering disease, especially pemphigus and suggests their positions in the therapeutic ladder.
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ORIGINAL ARTICLES Top

Hypersensitive reaction to tattoos: A growing menace in rural India p. 291
BM Shashikumar, MR Harish, B Shwetha, M Kavya, K Deepadarshan, HN Phani
DOI:10.4103/ijd.IJD_210_16  
Background: Increased enthusiasm toward newer fashion trends among rural India along with the lack of government regulation has led to increased tattoo reactions. Objective: The objective of this study is to describe various clinical manifestations of hypersensitive reactions to tattoo ink reported at a tertiary care hospital in Mandya district. Materials and Methods: An observational study was carried out over a period of 1 year from June 2014 to May 2015 at Mandya Institute of Medical Sciences, Mandya. All the patients reporting with allergic reaction due to tattooing were included in the present study after obtaining informed consent. Transient acute inflammatory reaction, infections, and skin diseases localized on tattooed area were excluded from this study. A detailed history regarding the onset, duration and color used for tattooing were collected. Cutaneous examination and biopsy was to done to know the type of reaction. Results: Fifty cutaneous allergic reactions were diagnosed among 39 patients. Mean age of subjects was 22 years and mean duration before the appearance of lesion was 7 months. Common colors associated with reactions were red (53.9%), black (33.3%), green (5.1%), and multicolor (7.7%). Itching was the predominant symptom. Skin lesions mainly consisted of lichenoid papules and plaques, eczematous lesions, and verrucous lesions. Lichenoid histopathology reaction was the most common tissue allergic reaction. Conclusion: Increasing popularity of tattooing among young people has predisposed to parallel increase in adverse reactions. Red pigment is most common cause of allergic reaction in the present study, and lichenoid reaction is the most common reaction.
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Prospective analysis of skin findings in surgical critically Ill patients intensive care unit p. 297
Suzan Demir Pektas, Arzu Kahveci Demir
DOI:10.4103/ijd.IJD_605_16  
Background: Intensive Care Units (ICUs) are places where critically ill patients are managed. Aim: We aimed to investigate skin disorders that developed in critically ill surgical patients during their stay in the ICU. Methods: The prevalence of dermatological disorders and factors affecting their clinical features was prospectively analyzed in surgical ICU patients. We recorded age, sex, type of ICU, comorbidities, skin disorders, time to consultation, duration of ICU stay, and mortality rate. Results: Our study included 605 patients (mean age of 60.1 ± 20.2 years; 56.4% males). Seventy-three (12.1%) patients were consulted with the Dermatology Department, among which 28.8% had infectious dermatological lesions, 26% dermatoses, and 45.2% drug reactions. The most common infectious dermatological disorder was wound infection (55.6%), the most common drug reaction was maculopapular drug eruption (75.8%), and the most common dermatosis was frictional blisters (47.4%). Multiple comorbidities, hypertension, diabetes mellitus, coronary artery disease, Parkinson disease, and stroke increased dermatological disorders (P < 0.05). The consulted patients had a median ICU stay of 7 days (range 2–53 days); consultation was significantly more common when it exceeded 10 days (74% vs. 26%, P < 0.05). The consulted patients died more commonly (P < 0.05). Infectious dermatological disorders and dermatoses were more common in patients older and younger than 50 years, respectively (P < 0.05). Dermatoses were more common among women (P < 0.05). The median time to consultation was 6 (2–30) days; it was longest for dermatological infections and shortest for dermatoses (P < 0.05). Infectious dermatological disorders were significantly more common among the deceased patients (P < 0.05). Conclusion: Multiple factors including multiple comorbidities, duration of ICU stay, time to consultation, and mortality increase dermatological disorders among surgical ICU patients.
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Demographic characteristics and association of serum Vitamin B12, ferritin and thyroid function with premature canities in Indian patients from an urban skin clinic of North India: A retrospective analysis of 71 cases p. 304
Sidharth Sonthalia, Adity Priya, Desmond J Tobin
DOI:10.4103/ijd.IJD_221_17  
Background: The incidence of self-reported premature hair graying (PHG) seems to be on the rise. PHG has a profound impact on the patient's quality of life. It remains an incompletely understood etiology with limited and modest treatment options. Aim: The evaluation of the demographic and clinical profile of patients with premature canities, and exploration of the association of this entity with certain systemic disorders suspected to be related to its etiology. Methods: Seventy-one cases of premature canities (onset noticed by patients before 25 years of age) presenting to an urban skin clinic in Gurugram, India, between September 2012 and September 2015 with this complaint were retrospectively analyzed. The patient records were retrieved that provided details of the onset, duration and pattern of involvement, history, and examination findings (scalp, cutis, and general physical). Since all these patients had been screened for anemia, thyroid disorder, fasting blood glucose, and Vitamin B12 levels at the time of presentation, these parameters were also available for analysis. Results: The mean age at onset of graying was 10.2 ± 3.6 years (range: 5–19 years), with an almost equal gender distribution. The earliest age of onset recorded was 5 years. A positive family history of PHG (at least one of the biological parents or siblings) was obtained in 64 (90.1%) of the cases. The temporal regions of the scalp (35.2%) were most commonly involved followed by the frontal region (18.3%). Hypovitaminosis B12 and hypothyroidism showed significant association with the disorder, whereas anemia, serum ferritin, and fasting blood glucose did not. Conclusion: The age of onset of hair graying can be as low as 5 years. Temporal and frontal areas are the most commonly involved sites. A strong family history, Vitamin B12 deficiency, and hypothyroidism are strongly associated with PHG. Larger case–control studies are mandated for discerning the correlation of these and other risk factors with PHG.
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SPECIAL ARTICLE Top

Terry's nails: A sign of systemic disease p. 309
Anna B Witkowska, Thomas J Jasterzbski, Robert A Schwartz
DOI:10.4103/ijd.IJD_98_17  
Terry's nails are a type of apparent leukonychia, characterized by ground glass opacification of nearly the entire nail, obliteration of the lunula, and a narrow band of normal, pink nail bed at the distal border. The aim of this study is to guide clinical practice by reviewing all of the data concerning Terry's nail that have become available since the original description by Terry in 1954, with particular reference to all clinical features, associated medical conditions, pathogenesis, and necessary workup. PubMed was searched using the keywords “leukonychia“ and “Terry nails.“ Although the abnormality can occur with normal aging, Terry's nails can also be an indication of an underlying medical condition, most notably, cirrhosis, chronic renal failure, and congestive heart failure. A change in nail bed vascularity, secondary to overgrowth of connective tissue, is thought to be responsible, with nail bed biopsy revealing telangiectasias in the distal band. The differential diagnosis for Terry's nails includes half-and-half nails (Lindsay's nails), Muehrcke's nails, and true leukonychia totalis/partialis. Having the ability to delineate these nail findings can be a valuable tool in clinical practice as each entity is associated with a different set of systemic conditions. Terry's nails highlight the intimate connection between nail changes and systemic disease as well as the importance of thorough nail inspection with every physical examination.
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CASE REPORTS Top

Solitary collagenoma of the labium majus: A rare occurrence p. 312
Kavita Bisherwal, Archana Singal, Deepika Pandhi, Vaibhav Girotra
DOI:10.4103/ijd.IJD_288_16  
Collagenomas are connective tissue nevi representing hamartomatous proliferation of collagen. Isolated collagenomas are of rare occurrence. They are sporadically acquired, and lesions are often localized to a single body region. We described a case of solitary collagenoma in a 23-year-old woman, confirmed on histopathology and special stains for collagen, involving an uncommon site such as labium majus. A high index of suspicion for a skin-colored circumscribed solitary growth and a low threshold for biopsy often help to arrive at a final diagnosis.
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Neurolymphomatosis in primary cutaneous CD4+ pleomorphic small/medium-sized T-cell lymphoma mimicking Hansen's disease p. 315
Anza Khader, Mary Vineetha, Mamatha George, Shiny Padinjarayil Manakkad, Sunitha Balakrishnan, Uma Rajan
DOI:10.4103/ijd.IJD_553_16  
Neurolymphomatosis (NL) refers to nerve infiltration by neurotropic neoplastic cells in the setting of a known or an unknown hematological malignancy. It typically presents as painful or painless peripheral mononeuropathy, mononeuritis multiplex, polyneuropathy, polyradiculopathy, or cranial neuropathy. A 32-year-old male presented with a hyperpigmented hypoesthetic plaque over the anterolateral aspect of the right leg with thickening of the right common peroneal nerve and foot drop clinically diagnosed as Hansen's disease. Biopsy taken from skin showed infiltrates of pleomorphic small and medium sized lymphocytes in the dermis and subcutis. On immunohistochemistry, the cells were positive for CD3, CD4 and negative for CD8, CD20, and CD30. Ultrasonography-guided fine-needle aspiration of the thickened nerve showed infiltrates of atypical lymphoid cells. Based on these findings, a diagnosis of NL in primary cutaneous CD4+ pleomorphic small/medium-sized T-cell lymphoma was made. The disease responded to systemic chemotherapy and localized radiotherapy with no evidence of relapse during 3 years follow-up. NL in primary cutaneous CD4+ pleomorphic small/medium-sized T-cell lymphoma presenting with manifestations redolent of Hansen's disease is not described in available literature. This case also demonstrates the utility of fine needle aspiration of nerve, a minimally invasive procedure in the diagnosis of NL.
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Desmoid tumor of rectus abdominis presenting with Grey-Turner's and Cullen's Sign: A report of a rare case p. 318
Angoori Gnaneshwar Rao, T Swathi, Saba Syeda Farheen, Amit Kolli, Sharanya Hari, Uday Deshmukh Reddy, Kondapi Deepak, Kranthi Jagadevapuram
DOI:10.4103/ijd.IJD_168_17  
Desmoid tumor of rectus abdominis presenting with Grey-Turner's and Cullen's sign is rare. Herein, we report desmoid tumor of rectus abdominis in a 64-year-old multiparous female who presented with ecchymosis involving left flank and around the umbilicus. Histopathological examination of biopsy from the tumor confirmed the diagnosis of the desmoid tumor. She was referred to a surgeon for radical resection.
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CORRESPONDENCES Top

Descriptive versus analytical studies in a clinical setup p. 321
Kanica Kaushal
DOI:10.4103/0019-5154.206187  
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Prospective study design conundrum: Disease registry for cutaneous leishmaniasis p. 321
Kanica Kaushal
DOI:10.4103/0019-5154.206188  
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Cutaneous angiosarcoma mimicking panniculitis in the lower extremities p. 322
Sumeyre Seda Ertekin, Ezgi Ozkur, Cem Leblebici, Mehmet Salih Gürel, Asli Vefa Turgut Erdemir
DOI:10.4103/ijd.IJD_392_16  
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QUIZ Top

Widespread indurated plaques and nodules p. 325
Evelyn Yap, Senhong Lee, Kwee Eng Tey, Siew Eng Choon
DOI:10.4103/ijd.IJD_597_16  
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