Misnomers in Dermatology: An Update

The name of a condition in dermatology, gives a clue regarding the clinical feature, etiology, or histopathology of the disease. A disease might have been termed wrongly due to its resemblance to another known condition. Misnomers often mislead a physician regarding the etiology or histopathology of the condition. Here is a list of misnomers, with explanation, and the appropriate name in parentheses.     

Drug Eruptions: An 8-year Study Including 106 Inpatients at a Dermatology Clinic in Turkey

Background:

Few clinical studies are found in the literature about patients hospitalized with a diagnosis of cutaneous drug eruption.

Aims:

To determine the clinical types of drug eruptions and their causative agents in a hospital-based population.

Materials and Methods:

This retrospective study was performed in the Dermatology Department of Haseki General Hospital. Through 1751 patients hospitalized in this department between 2002 and 2009, inpatients diagnosed as drug eruption were evaluated according to WHO causality definitions. 106 patients composed of probable and possible cases of cutaneous drug eruptions were included in this study.

Results:

Seventy one females and 35 males were evolved. Mean age was 44.03±15.14. Duration between drug intake and onset of reaction varied from 5 minutes to 3 months. The most common clinical type was urticaria and/or angioedema in 48.1% of the patients, followed by maculopapular rash in 13.2%, and drug rash with eosinophilia and systemic symptoms in 8.5%. Drugs most frequently associated with cutaneous drug eruptions were antimicrobial agents in 40.5% of the patients, followed by antipyretic/anti-inflammatory analgesics in 31.1%, and antiepileptics in 11.3%.

Conclusion:

Urticaria and/or angioedema and maculopapular rash comprised majority of the drug eruptions. Rare reactions such as acute generalized exanthematous pustulosis, sweet syndrome, oral ulceration were also found. Antimicrobial agents and antipyretic/anti-inflammatory analgesics were the most commonly implicated drugs. Infrequently reported adverse reactions to myorelaxant agents, newer cephalosporins and fluoroquinolones were also detected. We suppose that studies on drug eruptions should continue, because the pattern of consumption of drugs is changing in every country at different periods and many new drugs are introduced on the market continuously.     

Psychological Interventions in Dermatology

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.     

Psychiatric Evaluation in Dermatology: An Overview

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.     

Triads in Dermatology

It is imperative for any dermatology resident to have a good knowledge of the various triads in dermatology. For an easy grasp over this topic, we have grouped the various triads on the basis of their etiologies.     

Vaccines in Dermatology

A vaccine is a biological preparation that improves immunity to a specific disease. More than two centuries have passed since the first successful vaccine for smallpox was developed. We’ve come a long way since. Today''s vaccines are among the 21^st century''s most successful and cost-effective public health tools for preventing diseases.     

Biologics in Dermatology: An Integrated Review

The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.     

Strengths and Limitations of Evidence-Based Dermatology

The need for understanding and reflecting on evidence-based dermatology (EBD) has never been greater given the exponential growth of new external evidence to inform clinical practice. Like any other branch of medicine, dermatologists need to acquire new skills in constructing answerable questions, efficiently searching electronic bibliographic databases, and critically appraising different types of studies. Secondary summaries of evidence in the form of systematic reviews (SR), that is, reviews that are conducted in a systematic, unbiased and explicit manner, reside at the top of the evidence hierarchy, because they are less prone to bias than traditional expert reviews. In addition to providing summaries of the best external evidence, systematic reviews and randomized controlled trials (RCTs) are also powerful ways of identifying research gaps and ultimately setting the agenda of future clinical research in dermatology. But like any paradigm, EBD can have its limitations. Wrong application, misuse and overuse of EBD can have serious consequences. For example, mindless pooling together of data from dissimilar studies in a meta-analysis may render it a form of reductionism that does not make any sense. Similarly, even highly protocolised study designs such as SRs and RCTs are still susceptible to some degree of dishonesty and bias. Over-reliance on randomized controlled trials (RCT) may be inappropriate, as RCTs are not a good source for picking up rare but important adverse effects such as lupus syndrome with minocycline. A common criticism leveled against SRs is that these frequently conclude that there is lack of sufficient evidence to inform current clinical practice, but arguably, such a perception is grounded more on the interpretation of the SRs than anything else. The apparent absence of evidence should not paralyze the dermatologist to adopt a state of therapeutic nihilism. Poor primary data and an SR based on evidence that is not up-to-date are also limitations that can only improve with better primary studies and updated reviews such as those done by the Cochrane Collaboration. Most dermatologists are interested in integrating the best external evidence with the care of individual patients and have been practicing good EBD without realizing it.     

Serendipity and its Role in Dermatology

Serendipity is a pleasant surprise of finding a particularly useful information while not looking for it. Significant historic events occurring as a result of serendipity include the discovery of the law of buoyancy (Archimedes principle) by the Greek mathematician Archimedes, of the Americas by Christopher Columbus and of gravity by Sir Isaac Newton. The role of serendipity in science has been immensely beneficial to mankind. A host of important discoveries in medical science owe their origin to serendipity of which perhaps the most famous is the story of Sir Alexander Fleming and his discovery of Penicillin. In the field of dermatology, serendipity has been responsible for major developments in the therapy of psoriasis, hair disorders, aesthetic dermatology and dermatosurgery. Besides these many other therapeutic modalities in dermatology were born as a result of such happy accidents.     

On the History of Classification in Dermatology

Since the early days of cutaneous medicine, naming of the entities had remained a confusing subject. Earlier texts of all ancient civilisations are almost similar in this topic The Biblical controversy regarding the actual translational meaning of the original Hebrew term Zara ‘at has become a centre of controversy amongst many research scholars of the medical history. Similar debate exists about the Ayurvedic term Kustha---- whether it meant leprosy or stood for a number of skin affliction is a matter of controversy. A scientific and rational classification system was, therefore needed. The process started with Galen and traversed a long path and ultimately with the eight orders classification system proposed by Robert Willan in the early part of the nineteenth century resolved the issue. This whole journey was eventful….almost all the great doyens of dermatology directly or indirectly contributed to this process. This overview will focus on the main such events of the medical history in nutshell.     

Efficacy and Tolerability of Topical Fixed Combination of Nadifloxacin 1% and Adapalene 0.1% in the Treatment of Mild to Moderate Acne Vulgaris in Indian Patients: A Multicenter,Open-Labelled,Prospective Study

Background:

A combination of topical retinoid and antibacterial therapy is often advocated for acne to enhance therapeutic efficacy.

Aims:

A preliminary study to evaluate the efficacy and tolerability of a topical fixed combination of nadifloxacin (1%) and adapalene (0.1%) in the treatment of mild to moderate acne in Indian patients.

Materials and Methods:

This was an open-labeled, phase 3 non-randomized, non-comparative study conducted at five centers (Ahmedabad, Nagpur, Thane, Bangalore, and Mumbai) across India. Of 119 enrolled patients with mild to moderate acne, 117 patients were evaluated at the end of the study for efficacy parameters. A fixed combination of nadifloxacin (1%) and adapalene (0.1%) topical gel was applied at the affected area once at night for a period of 8 weeks. Reduction in the total, inflammatory and non-inflammatory lesion counts from the baseline, investigator global assessment (IGA) and reduction in the severity of acne as per combined acne severity classification were the primary efficacy variables measured at 2 weeks, 4 weeks, and 8 weeks.

Results:

Overall, 98.3% patients showed a statistically significant progressive reduction in non-inflammatory lesion counts, inflammatory lesion counts, and total lesion counts over the study duration. By the end of 8 weeks, 75% of the patients had their global assessment scores approaching to normal healthy skin score. The adverse events were mild to moderate in severity.

Conclusion:

This preliminary study shows that a fixed combination of 1% nadifloxacin and 0.1% adapalene topical gel could be an effective and well-tolerated option for the treatment of mild to moderate acne vulgaris. However, further well-controlled, randomized and comparative evaluation of this combination is necessary.     

Topical Steroid Awareness and Abuse: A Prospective Study among Dermatology Outpatients

Background:Topical steroids are one of the most commonly abused drugs. There are only a few studies available which have highlighted the severity of this problem in India. However, these studies have concentrated mainly on the topical steroid abuse and its side effects over the face.Aims:The aim of this study was to know the awareness among the people about various commonly available topical steroids and their combinations irrespective of usage and to know the extent of misuse of these drugs. Along with this, we also tried to find the source of recommendation of these medicines which will help to sensitize people about this menace.Results:A total of 1000 adult patients were included in the study, out of which 809 (80.9%) patients had heard about at least one of the topical steroids or its combinations mentioned in the questionnaire. Six hundred and twelve (61.2%) patients had used these creams. Acne and pigmentation were the most common indications for which topical steroid was used. These medicines were recommended by general practitioners in 302 (49.5%) patients and pharmacists in 71 (11.6%) patients. Totally, 318 (51.9%) patients complained of some form of side effect after using these creams. Aggravation of the symptoms and increased pigmentation were the most common adverse effects.Conclusion:Misuse of topical steroids not just over the face but also as a cream for any skin problem is quite common. Most of the times, it is recommended by general practitioners or pharmacists. It is very important to sensitize these people about the possible complications of these drugs and the extent of problem the society is facing because of irrational and unregulated use of these drugs.     

White Lesions in the Oral Cavity: A Clinicopathological Study from a Tertiary Care Dermatology Centre in Kerala,India

Context:

White lesions in the oral cavity may be benign, pre-malignant or malignant. There are no signs and symptoms which can reliably predict whether a leukoplakia will undergo malignant change or not. Many systemic conditions appear initially in the oral cavity and prompt diagnosis and management can help in minimizing disease progression and organ destruction.

Aim:

The aim of the paper was to study the clinical and histopathological patterns of white lesions in the oral cavity presented at the study setting and to study the factors associated with the histopathological patterns of the lesions.

Settings and Design:

A hospital based cross-sectional study of patients with white lesions in the oral cavity attending the Department of Dermatology and Venereology, Medical College, Thiruvananthapuram was done.

Materials and Methods:

After taking a detailed history, microscopic examination of Potassium hydroxide smear and an oral biopsy with histopathologial examination was done.

Results:

Out of the 50 patients in the study, clinically the diagnoses made were Lichen planus (32 patients; 64%), Frictional Keratosis (4;8%), Dysplasia (2;4%), Oral Hairy Leukoplakia (1;2%), Pemphigus Vulgaris (2;4%), Cutaneous Lupus Erythematosus (1;2%), Oral Submucous fibrosis (3;6%) and Oral Candidiasis alone (5;10%). Out of the 45 patients who had undergone biopsy, 25 (55.6%) had Lichen planus, 9 (20%) had Frictional Keratosis and mild Dysplasia was found in 4 (8.9%) patients.

Conclusion:

The measure of agreement between the clinical and pathological diagnosis was only 32%. Older age, difficulty in opening the mouth, consumption of non-smoked tobacco, site of the lesion (gingival, floor of mouth or lingual vestibule) and presence of tenderness on the lesion were significantly associated with Dysplasia.     

A Simple Instrument Designed to Provide Consistent Digital Facial Images in Dermatology

Photography has proven to be a valuable tool in the field of dermatology. The major reason for poor photographs is the inability to produce comparable images in the subsequent follow ups. Combining digital photography with image processing software analysis brings consistency in tracking serial images. Digital photographs were taken with the aid of an instrument which we designed in our workshop to ensure that photographs were taken with identical patient positioning, camera angles and distance. It is of paramount importance in aesthetic dermatology to appreciate even subtle changes after each treatment session which can be achieved by taking consistent digital images.     

Role of Clinical Images Based Teaching as a Supplement to Conventional Clinical Teaching in Dermatology

Introduction:

Clinical Dermatology is a visually oriented specialty, where visually oriented teaching is more important than it is in any other specialty. It is essential that students must have repeated exposure to common dermatological disorders in the limited hours of Dermatology clinical teaching.

Aim:

This study was conducted to assess the effect of clinical images based teaching as a supplement to the patient based clinical teaching in Dermatology, among final year MBBS students.

Methods:

A clinical batch comprising of 19 students was chosen for the study. Apart from the routine clinical teaching sessions, clinical images based teaching was conducted. This teaching method was evaluated using a retrospective pre-post questionnaire. Students’ performance was assessed using Photo Quiz and an Objective Structured Clinical Examination (OSCE). Feedback about the addition of images based class was collected from students.

Results:

A significant improvement was observed in the self-assessment scores following images based teaching. Mean OSCE score was 6.26/10, and that of Photo Quiz was 13.6/20.

Conclusion:

This Images based Dermatology teaching has proven to be an excellent supplement to routine clinical cases based teaching.     

Fixed Drug Eruption Due to Ornidazole

A 56-year-old male developed an ulcer on his glans penis and mucosae of upper and lower lips 3 days after taking ofloxacin, cephalexin, and ornidazole. Clinically, a provisional diagnosis of fixed drug eruption was made. The causative drug was confirmed by an oral provocation test which triggered a reactivation of all lesions only with ornidazole.     

Generalized Lichenoid Drug Eruption Associated with Imatinib Mesylate Therapy

Imatinib mesylate (IM), an anticancer drug, has been widely used to treat chronic myeloid leukemia (CML), gastrointestinal stromal tumors (GIST), and dermato-fibrosarcoma protuberans. Cutaneous reactions to IM have been reported to occur in varying number of patients in different case series. Non-lichenoid cutaneous reactions secondary to IM have been well-documented in the literature and are the commonest non-hematologic adverse reactions associated with its use. Lichenoid drug eruption (LDE) associated with IM therapy has rarely been reported in the literature. A case of a generalized LDE associated with IM therapy has been described here for its rarity and interesting clinical presentation. As the clinical usage of IM is increasing, one might expect an increasing number of similar patients in the future. It is thus important to realize the potential of IM to produce LDE and to differentiate this entity from idiopathic lichen planus. In the present article, the reports of IM-associated LDE, described in the PubMed and Medline database (in English language literature), have also been reviewed.