IJD
Indian Journal of Dermatology
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  Official organ of AADV
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   2013| January-February  | Volume 58 | Issue 1  
    Online since December 31, 2012

 
 
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E-IJD - CASE REPORTS
Allergic urticaria: A case report of rare skin allergy with a common mouthwash
Viresh Chopra, Harneet Chopra, Anamika Sharma
January-February 2013, 58(1):85-85
DOI:10.4103/0019-5154.105323  PMID:23372227
Chlorhexidine is a widely used antiseptic and disinfectant in medical and non-medical environments. Compared to its ubiquitous use, allergic contact dermatitis from chlorhexidine has rarely been reported and so its sensitization rate seems to be low. Chlorhexidine has been used for more than 50 years but it was only in the last two decades, that reports of immediate- type reactions to chlorhexidine were seen. Reactions ranging from localized urticaria to anaphylactic shock and hypersensitivity reactions, including delayed hypersensitivity reactions such as contact dermatitis, fixed drug eruptions, and photosensitivity reactions, began to appear more frequently. However the prevalence of contact urticaria and anaphylaxis due to chlorhexidine remains to be unknown. In this case report we have reported a case of urticaria due to oral use of chlorhexidine. The adverse reaction was confirmed by a skin prick test.
  5 3,039 21
CORRESPONDENCE
A case of Scedosporium prolificans osteomyelitis in an immunocompetent child, misdiagnosed as tubercular osteomyelitis
Monika Matlani, Ravinder Kaur, Shweta
January-February 2013, 58(1):80-81
DOI:10.4103/0019-5154.105319  PMID:23372223
  3 2,007 50
SYMPOSIUM
Primary psychiatric conditions: Dermatitis artefacta, trichotillomania and neurotic excoriations
Jillian W Wong, Tien V Nguyen, John YM Koo
January-February 2013, 58(1):44-48
DOI:10.4103/0019-5154.105287  PMID:23372212
Primary psychiatric conditions encountered in dermatology include dermatitis artefacta, trichotillomania (TTM) and neurotic excoriations. For these disorders, the primary pathologic condition involves the psyche; therefore, any cutaneous findings are self-induced. Herein, we review common primary psychiatric conditions in dermatology - dermatitis artefacta, neurotic excoriations and TTM - and examine their epidemiology, clinical presentation, differential diagnosis and treatment strategies. For all primary psychiatric disorders, the most effective underlying strategy is to first establish a strong therapeutic rapport with the patient. Various pharmacologic and non-pharmacologic therapies can then be attempted afterwards to successfully manage these patients.
  3 4,670 162
THERAPEUTIC ROUND
Comparative assessment of the efficacy and safety of sertaconazole (2%) cream versus terbinafine cream (1%) versus luliconazole (1%) cream in patients with dermatophytoses: A pilot study
HR Jerajani, C Janaki, Sharath Kumar, Meghana Phiske
January-February 2013, 58(1):34-38
DOI:10.4103/0019-5154.105284  PMID:23372210
Background : Sertaconazole is a new, broad spectrum, fungicidal and fungistatic imidazole with added antipruritic and anti-inflammatory activity that would provide greater symptomatic relief and hence would be beneficial in improving the quality of life for the patient with dermatophytoses. Aims and Objectives : To compare efficacy and safety of sertaconazole, terbinafine and luliconazole in patients with dermatophytoses. Materials and Methods : 83 patients with tinea corporis and tinea cruris infections were enrolled in this multicentre, randomized, open label parallel study. The initial 'Treatment Phase' involved three groups receiving either sertaconazole 2% cream applied topically twice daily for four weeks, terbinafine 1% cream once daily for two weeks, luliconazole 1% cream once daily for two weeks. At the end of treatment phase, there was a 'Follow-up Phase' at end of 2 weeks, where the patients were assessed clinically and mycologically for relapse. Results : Of the 83 patients, 62 completed the study, sertaconazole (n = 20), terbinafine (n = 22) and luliconazole (n = 20). The primary efficacy variables including change in pruritus, erythema, vesicle, desquamation and mycological cure were significantly improved in all the three groups, as compared to baseline, in the Treatment and Follow-up phase. Greater proportion of patients in sertaconazole group (85%) showed resolution of pruritus as compared to terbinafine (54.6%); and luliconazole (70%), (P < 0.05 sertaconazole vs terbinafine). There was a greater reduction in mean total composite score (pruritus, erythema, vesicle and desquamation) in sertaconazole group (97.1%) as compared to terbinafine (91.2%) and luliconazole (92.9%). All groups showed equal negative mycological assessment without any relapses. All three study drugs were well tolerated. Only one patient in sertaconazole group withdrew from the study due to suspected allergic contact dermatitis. Conclusion : Sertaconazole was better than terbinafine and luliconazole in relieving signs and symptoms during study and follow up period. At the end of 'Treatment Phase' and 'Follow-up' Phase, all patients showed negative mycological assessment in all three treatment groups suggesting no recurrence of the disease.
  3 8,790 472
SYMPOSIUM
Delusions of parasitosis
Jillian W Wong, John YM Koo
January-February 2013, 58(1):49-52
DOI:10.4103/0019-5154.105309  PMID:23372213
Patients with delusions of parasitosis (DOP) are more commonly recognized in dermatology practices today. However, dermatologists may feel uncomfortable treating these patients because of the psychiatric nature of their disorder. As a result of the fact that DOP patients strongly prefer to seek treatment from dermatologists rather than mental health professionals, it is important for dermatologists to be well equipped with a basic understanding of the disorder and with tools to assist this patient population. In this review, we discuss the epidemiology, presentation, differential diagnosis and treatment strategy for patients with DOP.
  2 6,100 167
BASIC RESEARCH
Role of skin prick test in allergic disorders: A prospective study in Kashmiri population in light of review
Roohi Rasool, Irfan Ali Shera, Saniya Nissar, Zaffar A Shah, Niyaz Nayak, Mushtaq A Siddiqi, Aga Syed Sameer
January-February 2013, 58(1):12-17
DOI:10.4103/0019-5154.105276  PMID:23372205
Background: Skin prick test (SPT) is the most effective diagnostic test to detect IgE mediated type I allergic reactions like allergic rhinitis, atopic asthma, acute urticaria, food allergy etc. SPTs are done to know allergic sensitivity and applied for devising immunotherapy as the therapeutic modality. Materials and Methods: This prospective study was conducted in the department of Immunology and Molecular medicine at SKIMS. A total of 400 patients suffering from allergic rhinitis, asthma and urticaria were recruited in this study. SPT was performed with panel of allergens including house dust mite, pollens, fungi, dusts, cockroach, sheep wool and dog epithelia. Allergen immunotherapy was given to allergic rhinitis and asthmatic patients as therapeutic modality. Results: In our study, age of patients ranged from 6 to 65 years. Majority of patients were in the age group of 20-30 years (72%) with Male to female ratio of 1:1.5. Of the 400 patients, 248 (62%) had urticaria, 108 (27%) patients had allergic rhinitis and 44 (11%) patients had asthma. SPT reaction was positive in 38 (86.4%) with allergic asthma, 74 (68.5%) patients with allergic rhinitis and 4 (1.6%) patient with urticaria, respectively. Allergen immunotherapy was effective in 58% patients with allergic rhinitis and 42% allergic asthma. Conclusion: Identifiable aeroallergen could be detected in 86.4% allergic asthma and 68.5% allergic rhinitis patients by SPT alone. Pollens were the most prevalent causative allergen. There was significant relief in the severity of symptoms, medication intake with the help of allergen immunotherapy.
  1 7,482 160
CORRESPONDENCE
Genital porokeratosis: A rare entity
Atul Dongre, Vijay Adhe, Swapnil Sanghavi
January-February 2013, 58(1):81-83
DOI:10.4103/0019-5154.105321  PMID:23372225
  1 2,672 87
E-IJD - CASE REPORTS
Chloroma of perianal region masquerading as perianal abscess
Rajeev Sen, Sunita Singh, Mahapatra S Qury, Sanjay Marwah, Garima Aggarwal, Shyam Singla
January-February 2013, 58(1):85-85
DOI:10.4103/0019-5154.105326  PMID:23372230
Chloroma, also called granulocytic sarcoma (GS) or Myeloid Sarcoma, is a rare malignant extra-medullary neoplasm of myeloid precursor cells. It is usually associated with myeloproliferative disorders but its appearance may precede the onset of leukaemia. The presence of a chloroma is certainly a sign of poor prognosis. We report a case of chloroma in a middle aged female without a prior history of leukemia in the perianal skin region with clinical diagnosis of perianal abscess. When there is no concomitant leukaemia, diagnosis of chloroma may be difficult. Differential diagnoses include acute lymphoblastic leukemia, large cell NHL, lymphoblastic lymphoma, Ewing's sarcoma and cutaneous T cell lymphoma.
  1 4,560 55
EDITORIALS
IJD ® : Consorting with CONSORT 2010
Saumya Panda, Hywel C Williams
January-February 2013, 58(1):2-5
DOI:10.4103/0019-5154.105271  PMID:23372203
  1 2,855 99
ORIGINAL ARTICLES
Direct immunofluorescence in cutaneous vasculitis: Experience from a referral hospital in India
BN Nandeesh, Rajalakshmi Tirumalae
January-February 2013, 58(1):22-25
DOI:10.4103/0019-5154.105280  PMID:23372207
Background : Cutaneous vasculitis is commonly recognized and biopsied, owing to ease of access. Most biopsies are also subjected to direct immunofluorescence (DIF), though the rates of positivity vary. This is an attempt to assess the utility of DIF and glean data that will help optimize the test. Objective : To assess the diagnostic utility of DIF in cutaneous vasculitis. Materials and Methods : All cases of suspected cutaneous vasculitis submitted for DIF between 2004 and 2010 were included. Clinical data, histopathologic diagnosis, DIF findings and additional tests such as anti nuclear antibody (ANA), anti neutrophil cytoplasmic antibody (ANCA) (where done) were noted. Results: There were 198 patients in the study group, with a female predominance. Purpura was the commonest clinical presentation. Extracutaneous involvement was noted in 29% of patients' i.e., joint pain, abdominal pain and hematuria. Leukocytoclastic vasculitis was the commonest histologic diagnosis. DIF showed an overall positivity of 39% (n = 77) with C3 in 26% (n = 52) and IgA in 23% (n = 46) cases. Forty one cases of suspected Henoch Schonlein Purpura (HSP) showed IgA positivity. The timing of biopsy ranged from <3 days to six months, with 38% being done within seven days. DIF was positive in 86% of biopsies performed within seven days of onset of lesions. Sixty percent of patients with extracutaneous manifestations showed deposits. Vascular deposits were also noted in dermatitis herpetiformis, dematomyositis and prurigo. Conclusion : DIF positivity is strongly influenced by the timing of the biopsy and the presence of extracutaneous features. Its clinical value is greatest in patients with HSP, being contributory in 90% of cases. Vascular deposits may be seen in non-vasculitic conditions and need clinicopathologic correlation.
  1 3,830 166
Psychological impairments in the patients with acne
Behnaz Behnam, Ramin Taheri, Raheb Ghorbani, Peyvand Allameh
January-February 2013, 58(1):26-29
DOI:10.4103/0019-5154.105281  PMID:23372208
Background: The psychological impacts of acne appearance and its-related negative emotional reactions have been proved; however, these reactions are varied in different populations. Aim: We investigated whether acne and its severity affected psychological functioning in those who suffered from this disorder among Iranians. Materials and Methods: One hundred and six patients with acne vulgaris who consecutively attended the dermatology outpatient clinics in Semnan city in 2008 were included. Among them, 103 patients met the study's inclusion criterion and agreed to participate. One hundred and six age and gender cross-matched healthy volunteers were included as controls that attended the clinic with their diseased relatives. All acne patients were evaluated using the Symptom Check List-90 (SCL-90). Results: According to the American Academy of Dermatology classification, 25.2% of the patients had mild acne, 50.5% moderate acne, and 24.3% severe acne. A higher percentage of participants than controls required further evaluation and psychological consultant when studying each psychological problem. The most common psychological symptoms requiring treatment due to disturbed daily activities in acne group were psychoticism (34.0%) and depression (31.1%), respectively. Significant positive correlations were observed between the duration of illness and SCL-90 total score. When evaluating the SCL-90 scores, patients with multiple sites of involvement were affected more severely than those with a single site of involvement. Conclusion: Acne vulgaris has significant effects on psychological status. Effective concomitant anti-acne therapy and psychological assessment make significant contributions for the mental health and should be strongly recommended.
  1 4,211 177
Evaluation of cutaneous drug reactions in patients visiting out patient departments of Indira Gandhi Government Medical College and Hospital (IGGMC and H), Nagpur
Sachin Hiware, Meena Shrivastava, Dharmendra Mishra, Jayesh Mukhi, Gaurav Puppalwar
January-February 2013, 58(1):18-21
DOI:10.4103/0019-5154.105279  PMID:23372206
Objectives: To detect cutaneous drug reactions through spontaneous reporting system in IGGMCand H, Nagpur and analyze them using standard assessment scales. Materials and Methods: An observational, prospective study was performed in patients attending dermatology OPD of IGGMC and H, Nagpur from 1 st June 05 to 31 st May 09. Patients were examined for cutaneous drug reactions (CDRs) by spontaneous Adverse Drug Reaction reporting system. Results: Among 2693 total ADRs reported, 872 (33.04%) were CDRs. Antimicrobials (55.5%) were the main drugs involved followed by NSAIDs (18.56%) and steroids (12.61%). Maculopapular rash (37.73%) followed by fixed drug eruption (17.2%) and urticaria (14.56%) were the most frequently observed CDRs. The common drugs causing CDRs were cotrimoxazole (20.41%), topical steroids (betamethasone), ibuprofen (7.91%), ampicillin (6.54%), diclofenac (4.7%) and iron dextran (3.44%). Conclusion : It was observed that commonly used drugs like antibiotics and NSAIDs lead to maximum number of CDRs. Hence strict vigilance is required while using them. This study provides a database of ADRs due to common drugs, which will help clinicians in safe use of these drugs.
  1 3,244 205
SYMPOSIUM
Psychiatric evaluation in dermatology: An overview
Sreyoshi Ghosh, Rishikesh V Behere, PSVN Sharma, K Sreejayan
January-February 2013, 58(1):39-43
DOI:10.4103/0019-5154.105286  PMID:23372211
Psychodermatology is an exciting field which deals with the close relationship that exists between dermatological and psychiatric disorders. A combined bio-psycho-social approach is essential for effective evaluation and treatment of these conditions. This review aims to give the practicing clinician an overview of psychiatric evaluation in patients with dermatological conditions.
  1 3,858 228
CASE REPORTS
Hemorrhagic gianotti-crosti syndrome in a one and half month old infant: An extremely unusual presentation
Nilendu Sarma, Uttam K Sarkar, Mrinal K Das, Somnath Das
January-February 2013, 58(1):65-67
DOI:10.4103/0019-5154.105313  PMID:23372217
Gianotti-Crosti syndrome is parainfectious exanthematous disease having unique presentation of small papulovesicular eruptions symmetrically over extensor surface of limbs and face in children. Hemorrhagic lesions are very rare and are always localized. Here, a case of EBV-induced Gianotti-Crosti syndrome with extensive hemorrhagic vesicles in a one and half month old infant, possibly induced by Epstein Barr virus, is reported. Neither the involvement of the disease at this early age nor the extensive hemorrhagic vesicles as the predominant presentation is reported before.
  - 6,402 83
Cutaneous lymphangiosarcoma following chronic lymphedema of filarial origin
Abhijit S Acharya, KR Sulhyan, RV Ramteke, VY Kunghadkar
January-February 2013, 58(1):68-70
DOI:10.4103/0019-5154.105314  PMID:23372218
We are reporting a case of 36 yr old female with chronic filarial lymphedema of both legs. Subsequently she developed lymphangiosarcoma of her left leg which was confirmed histologically and on immunohistochemistry. Only three more cases of lymphagiosarcoma occurring in patients with filarial lymphedema are reviewed from available literature.
  - 3,313 56
Chronic lymphedema of filarial origin: A very rare etiology of cutaneous lymphangiosarcoma
Shubhangi V Agale, Wasif Ali ZA Khan, Karishma Chawlani
January-February 2013, 58(1):71-73
DOI:10.4103/0019-5154.105315  PMID:23372219
Lymphedema-associated angiosarcoma also known as lymphangiosarcoma is the commonest type of cutaneous angiosarcoma. Post-mastectomy lymphedema is the most frequent cause, while chronic filarial lymphedema is one of the most uncommon etiology for development of lymphangiosarcoma. We report a case of a 50 year old male suffering from chronic filarial lymphedema of right lower extremity, presented with brownish nodules on the right leg, which were diagnosed histopathologically as lymphangiosarcoma.
  - 2,562 54
Keratoacanthoma centrifugum marginatum at an unusual site
Meghana M Phiske, Ganesh Avhad, HR Jerajani
January-February 2013, 58(1):74-76
DOI:10.4103/0019-5154.105316  PMID:23372220
Keratoacanthoma (KA) is a rapidly evolving tumor, composed of keratinizing squamous cells originating in pilosebaceous follicles and resolving spontaneously if left untreated. It is relatively uncommon in dark-skinned and occurs in middle aged individuals. Males are three times more affected than females. It presents as firm, rounded, flesh-colored or reddish papule; with a rapid growth phase followed by spontaneous healing over three months. Two types of KA exist i.e., solitary and multiple. There are three rare clinical variants of solitary KA, namely giant KA, keratoacanthoma centrifugum marginatum (KCM) and subungual KA. In KCM, lesions are large, reaching upto 20cms. There is peripheral extension with raised, rolled border and atrophy in the center. There is no tendency toward spontaneous involution. The most common locations are dorsa of hands and legs, lesions on scalp being rare. A rare case of KCM occurring on scalp which is an unusual site is reported.
  - 3,262 65
CME ARTICLE
Newer management options in leprosy
P Narasimha Rao, Suman Jain
January-February 2013, 58(1):6-11
DOI:10.4103/0019-5154.105274  PMID:23372204
Newer management options are needed for leprosy control even at present, as it is predicted that new cases of leprosy will continue to appear for many more years in future. This article detail newer methods of clinical grading of peripheral nerve involvement (thickening, tenderness and nerve pain which are subjective in nature) and the advances made in the use of Ultrasonography and Colour Doppler as an objective imaging tool for nerves in leprosy. It also briefly discusses the newer drugs and alternative regimens as therapeutic management options which hold promise for leprosy in future.
  - 18,118 1,359
CORRESPONDENCE
Authors' reply
Caroline T Nguyen, Siba P Raychaudhuri
January-February 2013, 58(1):81-81
PMID:23372224
  - 1,315 28
Sclerotherapy for the treatment of pyogenic granuloma
S Sacchidanand, V Purohit
January-February 2013, 58(1):77-78
DOI:10.4103/0019-5154.105317  PMID:23372221
  - 2,284 88
Relapse of hand foot and mouth disease: Are we at more risk?
Nilendu Sarma
January-February 2013, 58(1):78-79
DOI:10.4103/0019-5154.105318  PMID:23372222
  - 3,482 73
DERMATOPATHOLOGY ROUND
Benign vs. Malignant skin adnexal neoplasms: How useful are silhouettes?
Rajalakshmi Tirumalae, MO Roopa
January-February 2013, 58(1):30-33
DOI:10.4103/0019-5154.105282  PMID:23372209
Background: Skin adnexal tumors are daunting diagnostic problems. Cytologic atypia does not always imply malignancy and "typia" does not underscore a benign course. Bernard Ackerman first described criteria on silhouettes that enable distinction between the two. Aims: To evaluate the histologic features on silhouettes of benign and malignant skin adnexal tumors. To identify overlaps and confounding features. Materials and Methods: A blinded retrospective review of all skin adnexal neoplasms between 1995 and 2007 was done, with a total of 68 cases. We studied 16 histologic parameters on scanner view and categorized them as benign or malignant. They were compared with the final histologic diagnosis. Statistical analysis was performed using chi-square test. Results: 15 criteria attained statistical significance. Features that proved highly sensitive and specific were: Circumscription, ulceration, uniform size of cell aggregates, discrete arrangement, preserved adnexae and necrosis. Criteria that were sensitive but not very specific include: Symmetry, V-shape, vertical orientation, smooth margins, compressed fibrous tissue, type of clefting, shelling out and geometric shapes. Presence of epithelial cells in singles was not helpful. Conclusion: Malignant skin adnexal tumors are differentiated accurately from benign ones by their contrasting silhouettes. Pathologists should heed the impression formed on scanner view, before evaluating cytologic features.
  - 6,777 178
E-IJD - CASE REPORTS
Papulonecrotic tuberculid with positive acid-fast bacilli
Ren Jun, Liu Xiao-kun, Pan Chao, Li Xin-sheng, Wang Xiao-hui, Yan Xin, Chen Mei-hua, Zeng Kang
January-February 2013, 58(1):85-85
DOI:10.4103/0019-5154.105324  PMID:23372228
Two patients suffered from 'boils' on their arms and/or thighs for several months. A diagnosis of papulonecrotic tuberculid (PNT) was made based on clinical, laboratory parameters, histopathology, and a prompt response to multi-drug anti-tuberculosis treatment. We checked the pathological sections carefully and finally found a small amount of positive acid-fast bacilli. We analyzed the clinical and histopathological features of PNT in order to offer reference of preventing and controlling the disease.
  - 5,081 77
Morphea simulating paucibacillary leprosy clinically and histopathologically
José Saulo Torres Delgado, Marília Lopes Cavalcanti, Bernard Kawa Kac, Claudia Lopes Pires
January-February 2013, 58(1):85-85
DOI:10.4103/0019-5154.105325  PMID:23372229
Clinically and histopathologically paucibacillary leprosy shows similar features with initial morphea. In this case we report a 24 yr-old male patient who presented to our dermatology department with diagnosed paucibacillary leprosy by his local dermatologist, and confirmed by perineurovascular lymphocytic infiltrate in the histopathological exam. On physical examination we found new plaque lesions that were suggestive of morphea with alteration of sensitivity. A new biopsy was performed showing sclerotic superficial dermis with thickening of the collagen bundles in deep dermis and linear arrays lymphocytic infiltrate between the collagen bundles that confirm the diagnosis of morphea.
  - 3,166 58
EDITORIALS
IJD ® 2012: A Progress Report
Koushik Lahiri
January-February 2013, 58(1):1-1
DOI:10.4103/0019-5154.105267  PMID:23372202
  - 2,419 70
IJD® QUIZ
An asymptomatic papule on forearm
Vijay Adhe, Atul Dongre
January-February 2013, 58(1):84-84
DOI:10.4103/0019-5154.105322  PMID:23372226
  - 4,150 129
SYMPOSIUM
Relevant issues in pharmacotherapy of psycho-cutaneous disorders
Sreyoshi Ghosh, Rishikesh V Behere, PSVN Sharma, S Savitha
January-February 2013, 58(1):61-64
DOI:10.4103/0019-5154.105311  PMID:23372216
Psychiatric disorders frequently co-occur with dermatological conditions and psychotropic agents may be indicated in treating the underlying psychiatric symptoms. Use of psychotropics can be associated with significant cutaneous adverse effects as well as drug interactions with pharmacological agents used in treatment of the dermatological conditions. Knowledge of indication, contraindication, side effects, and interactions of psycho-tropics is essential for the practicing dermatologist in managing psycho-dermatological conditions. This review aims at discussing relevant issues in pharmacological management of psycho-cutaneous disorders.
  - 3,511 173
Our experience in a psychodermatology liaison clinic at Manipal, India
Shrutakirthi D Shenoi, Smitha Prabhu, B Nirmal, Shailee Petrolwala
January-February 2013, 58(1):53-55
DOI:10.4103/0019-5154.105310  PMID:23372214
Psychodermatology is an emerging specialty in dermatology which deals with the interactions between mind and skin. Psychocutaneous diseases can be either primary psychiatric or primary cutaneous, with various degrees of associations between psyche and skin. Unless the dermatologist cultivates a special interest in this field, many an invisible mental disorder may be missed leading to sub optimal treatment of the visible skin condition. Though Dermatology Psychiatry liaison clinics are common in Europe and other western countries, it is just an emerging concept in India.Here we describe the working pattern of psychodermatology liaison clinic established in Manipal in August 2010 and describe briefly the type of cases attended to.
  - 3,101 111
Psychological interventions in dermatology
Piyanjali de Zoysa
January-February 2013, 58(1):56-60
DOI:10.4103/0019-5154.105312  PMID:23372215
The objective of this paper is to introduce and emphasize the importance of psychological interventions for those with dermatological conditions. In keeping with the current literature, the author envisages a two-tier approach in the provision of such psychological interventions. Firstly, most patients with dermatology conditions may not require psychological change. Instead, they could be approached with effective doctor-patient communication skills, within a context of empathy and positive regard. At the second tier, however, based on the clinical interview, some patients may require varying degrees of psychological change in order to better manage their illness. In such a context, a dermatologist with training in psychotherapy would be required. In the absence of such a person, the patient may be referred to a psychologist or another mental health professional trained in psychotherapy.
  - 2,786 143
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