Psychiatric morbidity in vitiligo: prevalence and correlates in India

BACKGROUND

Vitiligo, a common pigmentary disorder, is recognized to be associated with a high psychiatric morbidity, yet compared to other dermatological disorders like leprosy, psoriasis, etc., it has not been subjected to detailed evaluation of its psychological consequences. The data from the developing countries on this aspect in particular is meager.

METHODS

One hundred and thirteen cases with vitiligo were evaluated along with 55 healthy controls comparable for sociodemographic profile and matched on attitude to appearance scale. Clinical details, impact of illness, associated dysfunction and psychological morbidity were additionally assessed.

RESULTS

Twenty-eight patients with vitiligo were found to have psychiatric morbidity, a clinic prevalence rate of 25% (95% confidence interval 20.3-29.3%). The majority of the cases had a diagnosis of adjustment disorder. Psychiatric morbidity was significantly correlated with dysfunction arising out of illness.

CONCLUSIONS

Vitiligo is associated with high psychiatric morbidity. There is a need to develop cross-cultural database on psychosocial aspects and psychiatric morbidity associated with vitiligo.

A randomised controlled trial of the effect of anticipation of a blood test on blood pressure

Blood pressure is affected by situational anxiety, such as the white coat effect. We hypothesised that blood pressure would also be affected by anticipation of a blood test. Volunteer subjects were recruited on the campus of Birmingham University. Subjects were randomly assigned to intervention and control groups. After a period of rest, three seated blood pressure measurements were taken at 1-min intervals using an electronic sphygmomanometer. Between the second and third measurements subjects in the intervention group were told that a blood test would be carried out after the last measurement. No blood test was carried out. Three blood pressure measurements were made in all 213 randomised subjects. Analysis was by intention-to-treat. In the control group mean systolic and diastolic blood pressure fell in successive measurements. Between the second and third measurements mean systolic blood pressure fell by 1.4 mm Hg in the control group and rose by 2.6 mm Hg in the intervention group (difference 4.0 mm Hg, P < 0.0001). A rise in diastolic blood pressure between the second and third measurements did not reach statistical significance. It was concluded that anticipation of a blood test affects measured systolic blood pressure in volunteers. The practice of taking blood tests at the same time as measuring blood pressure may potentially bias estimations of blood pressure.

Fabric-staining properties and washability of a novel liposomal dithranol formulation

AIM

To test the staining potential of a novel liposomal dithranol gel on different types of fabrics and compare it with the only commercially available dithranol preparation in India, Derobin.

METHODS

Pure cotton, pure polyester and four blends of the two fabrics were tested for staining and washability.

RESULTS

Both products showed the least staining and spreading on pure cotton with progressively worse stains as the proportion of polyester in the fabric increased. When compared with each other the liposomal dithranol gel showed markedly lighter staining than Derobin on all fabrics. It also washed off completely with water whereas the Derobin stains could not be washed off, even with detergent.

CONCLUSION

The liposomal gel due to its superior staining properties may potentially increase the acceptability of dithranol amongst psoriasis patients.

Lack of effect of dimethylsulphoxide in cutaneous amyloidosis

OBJECTIVE

To evaluate dimethylsulphoxide (DMSO) as a topical therapeutic agent for the treatment of two major variants of primary, localized, cutaneous amyloidosis -- macular amyloidosis (MA) and papular/lichen amyloidosis (LA) -- using a monocentric, open, prospective trial.

METHODS

A total of 25 patients with histopathologically proven cutaneous amyloidosis - MA, LA and BA (biphasic amyloidosis) (13 MA, seven LA, five BA) were requested to undertake a once daily application of either 50% or 100% DMSO for 12 weeks. Progress was regularly assessed with a scoring system for pruritus, pigmentation and papules.

RESULTS

In 17 (68%) cases, the scores for pruritus decreased but never completely disappeared in any of the patients. Lightening of the pigmentation was noted in only six (24%) cases and the scores for the papules were decreased in only two out of 12 (16.6%) patients. Post-treatment skin biopsies did not reveal a reduction/disappearance of the amyloid deposits. In the follow-up period, the relapse rate was 100%.

CONCLUSION

DMSO does not have an anti-pruritic effect or amyloid-dissolving properties. As the results are partial and transient, it is concluded that DMSO is not a satisfactory treatment for cutaneous amyloidosis.

Mucocutaneous adverse effects of hydroxyurea: a prospective study of 30 psoriasis patients

Hydroxyurea is an anti-tumour agent most commonly used to treat chronic myeloproliferative disorders in doses up to 4 g per day. Dermatological adverse effects reported so far have been observed predominantly in these patients. As we are treating selected psoriasis patients with low dose hydroxyurea we attempted to define the spectrum and chronology of dermatological adverse effects in this group of patients prospectively. Of the 29 evaluable patients, 19 (65.5%) developed a mucocutaneous adverse reaction after a mean duration of 6.4 weeks of treatment. Pigmentation of nails, skin or mucosa was the most common observation and was seen in 17 (58.6%) patients. Other less common findings were xerosis, diffuse alopecia, oedema of the legs, oral ulcers and actinic psoriasis. Adverse effects subsided in 11 (57.9%) patients during a mean follow up of 18 weeks. Three hitherto unreported side-effects - scleral pigmentation, acquired ichthyosis and pigmentation of lunula of the nails - were noted. This first study of dermatological adverse effects of hydroxyurea therapy on Asian psoriatic patients reveals several new findings. Pigmentation of skin, nails and mucosa appears to be very common and occurs early. Serious dermatological side-effects probably do not occur with low dose (up to 1.5 g per day) hydroxyurea in patients with psoriasis.

Rediscovering hydroxyurea: its role in recalcitrant psoriasis

BACKGROUND

There is an acute paucity of second-line systemic agents for the treatment of extensive chronic plaque psoriasis (CPP). Recent studies using hydroxyurea in patients with HIV infection and sickle cell anemia have rekindled interest in this old drug and have provided more data regarding safety and dosage.

OBJECTIVE

We wanted to test the efficacy and tolerability of hydroxyurea in patients with extensive CPP who had to discontinue first-line oral agents for any reason.

METHODS

The study was a prospective nonrandomized series. Thirty-one patients, including 26 with prior history of systemic antipsoriatic therapy were given hydroxyurea 1-1.5 g per day for a median duration of 36 weeks. They were followed up for a mean period of 36.1 +/- 13.8 weeks.

RESULTS

Almost 75% of the patients showed an adequate response (35% reduction in Psoriasis Area and Severity Index at or before 8 weeks) with over half showing more than 70% reduction in PASI score. All adverse effects were mild and reversible and none of the patients required cessation of therapy.

CONCLUSION

Hydroxyurea is an effective, very safe but relatively slower acting alternative for patients with extensive CPP over the short-to-medium term.

Zosteriform pilar leiomyoma

Pilar leiomyomas are usually multiple and are commonly found on the extensor aspects of the arm, trunk, and face. They are rarely distributed in a linear fashion or seem to follow a dermatome. We report a case of painful, unilateral, zosteriform cutaneous leiomyoma in a 25-year-old housewife. Histopathology revealed interlacing smooth muscle bundles arising from arrector pili muscles. Nifedipine (10 mg) twice daily was remarkably effective in diminishing the pain in our patient.

Decreased non-MHC-restricted (CD56+) killer cell cytotoxicity after spaceflight

Cytotoxic activity of non-major histocompatibility complex-restricted (CD56+) (NMHC) killer cells and cell surface marker expression of peripheral blood mononuclear cells were determined before and after spaceflight. Ten astronauts (9 men, 1 woman) from two space shuttle missions (9- and 10-day duration) participated in the study. Blood samples were collected 10 days before launch, within 3 h after landing, and 3 days after landing. All peripheral blood mononuclear cell preparations were cryopreserved and analyzed simultaneously in a 4-h cytotoxicity (51)Cr release assay using K562 target cells. NMHC killer cell lytic activity was normalized per 1,000 CD56+ cells. When all 10 subjects were considered as one study group, NMHC killer cell numbers did not change significantly during the three sampling periods, but at landing lytic activity had decreased by approximately 40% (P < 0.05) from preflight values. Nine of ten astronauts had decreased lytic activity immediately after flight. NMHC killer cell cytotoxicity of only three astronauts returned toward preflight values by 3 days after landing. Consistent with decreased NMHC killer cell cytotoxicity, urinary cortisol significantly increased after landing compared with preflight levels. Plasma cortisol and ACTH levels at landing were not significantly different from preflight values. No correlation of changes in NMHC killer cell function or hormone levels with factors such as age, gender, mission, or spaceflight experience was found. After landing, expression of the major lymphocyte surface markers (CD3, CD4, CD8, CD14, CD16, CD56), as determined by flow cytometric analysis, did not show any consistent changes from measurements made before flight.

Vitiligo: a retrospective comparative analysis of treatment modalities in 500 patients

The major non-surgical re-pigmenting therapies for vitiligo include psoralens and corticosteroids, used both topically and systemically. In an attempt to determine the best therapeutic option, we compared the efficacy of various treatment regimens used in our department for the treatment of vitiligo. We report herein our results with six different regimens used in our clinic. Data from five hundred vitiligo patients who attended the pigmentary disorders clinic at the Nehru Hospital, PGI, Chandigarh, was analysed. For the purpose of analysis, patients were arbitrarily divided into two groups based upon the body surface area (BSA) involved: Group A (<10% BSA involved) and B (>10% BSA involved). Group A was further divided into three subgoups of patients depending upon what treatment they received: R-I [topical clobetasol propionate+sun exposure]; R-II [topical psoralen+sun exposure (topical PUVASOL)]; R-III [topical psoralen+UVA (topical PUVA)]. Group B was also subdivided into three subgroups of patients who received: R-IV [oral dexamethasone pulse therapy + sun exposure]; R-V [systemic psoralen + sun exposure (systemic PUVASOL)]; R-VI [systemic psoralen + UVA (systemic PULVA)]. Patients who had undergone, one of the above mentioned regimens and had a regular monthly follow up until total re-pigmentation or for at least one year, whichever was earlier, were included in the final assessment of the therapeutic efficacy of that regimen. At the end of the study in Group A, 207 (89%) patients out of 232 on R-I; 73 (93%) out of 78 on R-II, and 15 (79%) out of 19 patients on R-III showed moderate to excellent re-pigmentation, respectively. In group B, 45 (81%) patients out of 55 on R-IV, 48 (84%) out of 57 on RV, and 22 (84%) patients out of 26 on R-VI showed moderate to excellent re-pigmentation. Statistically, in Group A, R-I & II were significantly better than R-III. However in Group B, there was no significant difference in the responses to R-IV, V, and VI. A positive family history of vitiligo did not seem to affect the response rate. Potent topical steroids used along with sun exposure and topical PUVASOL were the most effective forms of therapy for localised vitiligo. For the generalised form of the disease, we concluded that all the systemic modalities, oral steroids, PUVASOL and PUVA, are equally efficacious over a period of one year. Phototoxic reactions were, however, more common with PUVASOL.

Impact of combined Mycobacterium w vaccine and 1 year of MDT on multibacillary leprosy patients

A total of 20 bacteriologically positive multibacillary (MB) leprosy patients older than 18 years of age with a bacterial index (BI) of 2+ or greater were given standard World Health Organization multiple drug therapy (MDT-MB) for 12 consecutive months plus four intradermal doses of Mycobacterium w vaccine at 3 monthly intervals (Study group). Twenty age-matched MB patients were given WHO/MDT alone (Control group). The patients of both groups were followed up for 1 year. Improvements in the patients were periodically monitored by clinical (Ramu's score), bacteriological (SSS), histopathological (skin biopsy) and immunological (lepromin conversion) parameters. Study group patients showed more significant improvements in all parameters except for lepromin conversion compared to patients in the Control group. The incidence of type 1 reaction was more in the Study group (30% vs 10%), while the incidence of type 2 reaction was more in the Control group (25% vs 15%). Neuritis associated with reactions was seen more often in the Control group compared to the Study group (20% vs 10%). The addition of Mycobacterium w vaccine as an adjunct to the 1-year WHO/MDT regimen appears to be significantly more beneficial in MB leprosy patients with a high initial BI compared to WHO/MDT given alone. Studies on larger numbers of patients with extended follow up will be in order.

Comparison of calcipotriol and coal tar in conjunction with sun exposure in chronic plaque psoriasis: a pilot study

This study was a left-right comparison of the efficacy of 0.005% calcipotriol ointment and 5% coal tar ointment in conjunction with sun exposure in 10 patients with stable plaque psoriasis. After four weeks of therapy, the calcipotriol treated site showed a significantly faster fall in PASI compared to the coal tar treated site. At eight weeks, this difference was not significant with both sides showing comparable improvement in lesions, as shown by PASI values. There were no significant side effects from either therapy. We conclude that both calcipotriol and coal tar ointments have comparable efficacy in treating stable plaque psoriasis when used simultaneously with sun exposure, although the initial response to calcipotriol is faster.

Psychiatric morbidity in vitiligo and psoriasis: a comparative study from India

In a tertiary-care teaching hospital in India, dermatology outpatients with vitiligo (N=113) and psoriasis (N=103) were studied for psychiatric morbidity. The two groups were similar with regard to education, locality, religion, and attitude to appearance (ATT). Psoriasis cases were older, more often male, and more often married. The General Health Questionnaire (GHQ) assessed psychiatric morbidity rates at 33.63% and 24.7% for vitiligo and psoriasis, respectively. The ICD-10 psychiatric diagnoses in GHQ positive cases were: adjustment disorder (56% vs 62%), depressive episode (22% vs 29%) and dysthymia (9% vs 4%) in vitiligo and psoriasis, respectively. The Comprehensive Psychopathological Rating Scale (CPRS) assessed that depression, anxiety, and total psychopathology levels were similar in the two GHQ positive subgroups. Significant correlations were noted between psychopathology (GHQ CRPS), dysfunction as per Dysfunction Analysis Questionnaire (DAQ), and behavior change as per Impact of Skin Disease Scale (IMPACT), and all were more prominent in vitiligo.

Rediscovering hydroxyurea: its role in recalcitrant psoriasis

BACKGROUND

There is an acute paucity of second-line systemic agents for the treatment of extensive chronic plaque psoriasis (CPP). Recent studies using hydroxyurea in patients with HIV infection and sickle cell anemia have rekindled interest in this old drug and have provided more data regarding safety and dosage.

OBJECTIVE

We wanted to test the efficacy and tolerability of hydroxyurea in patients with extensive CPP who had to discontinue first-line oral agents for any reason.

METHODS

The study was a prospective nonrandomized series. Thirty-one patients, including 26 with prior history of systemic antipsoriatic therapy were given hydroxyurea 1-1.5 g per day for a median duration of 36 weeks. They were followed up for a mean period of 36.1 +/- 13.8 weeks.

RESULTS

Almost 75% of the patients showed an adequate response (35% reduction in Psoriasis Area and Severity Index at or before 8 weeks) with over half showing more than 70% reduction in PASI score. All adverse effects were mild and reversible and none of the patients required cessation of therapy.

CONCLUSION

Hydroxyurea is an effective, very safe but relatively slower acting alternative for patients with extensive CPP over the short-to-medium term.

Involvement of male genitalia in leprosy

Four hundred and sixty-seven male patients with leprosy were screened for genital involvement. Genital lesions were observed in 6.6% of all male cases of leprosy. They were seen most frequently in lepromatous leprosy (25.8%), followed by borderline lepromatous (13.3%) and borderline tuberculoid (1.4%) leprosy.

Safety and efficacy of glycolic acid facial peel in Indian women with melasma

BACKGROUND

Melasma is a common disorder of facial hyperpigmentation. Many modalities of treatment are available, but none is satisfactory.

MATERIALS AND METHODS

Twenty-five nonpregnant female patients with a minimum melasma area and severity index (MASI) of 15 were recruited in the study. After a detailed history and clinical examination under natural light and Wood's light, MASI was calculated and color photographs were taken of all patients. Patients were advised to carry out a prepeel program of daily application of topical sunscreens (sun protection factor-15, SPF-15) and 10% glycolic acid lotion at night for 2 weeks. Patients were then treated with 50% glycolic acid facial peel once per month for three consecutive months. At regular intervals and at the end of the follow-up period (3 months) after the last peel, the degree of improvement in pigmentation was assessed by remeasuring MASI. Side-effects, if any, were also recorded. The data obtained were statistically analyzed using Student's paired t-test and Spearman rank correlation coefficient test.

RESULTS

Improvement in melasma (reduction in MASI) was observed in 91% of patients (P < 0.01). Patients with epidermal-type melasma demonstrated a better response to treatment than those with mixed-type melasma (P < 0.05).

CONCLUSIONS

The prepeel program followed by 50% glycolic acid facial peel once per month for three consecutive months proved to be an effective treatment modality in Indian patients without any significant side-effects.

Silver(I) ion-selective membrane based on Schiff base-p-tert-butylcalix[4]arene

A PVC membrane electrode for silver(I) ion based on Schiff base-p-tert-butylcalix[4]arene is reported. The electrode works well over a wide range of concentration (1.0 x 10(-5)-1.0 x 10(-1) mol dm-3) with a Nernstian slope of 59.7 mV per decade. The electrode shows a fast response time of 20 s and operates in the pH range 1.0-5.6. The sensor can be used for more than 6 months without any divergence in the potential. The selectivity of the electrode was studied and it was found that the electrode exhibits good selectivity for silver ion over some alkali, alkaline earth and transition metal ions. The silver ion-selective electrode was used as an indicator electrode for the potentiometric titration of silver ion in solution using a standard solution of sodium chloride; a sharp potential change occurs at the end-point. The applicability of the sensor to silver(I) ion measurement in water samples spiked with silver nitrate is illustrated.

Costs of asthma treatment in Estonia

BACKGROUND

The aim of this study was to describe the distribution of the direct costs of asthma in Estonia by the type of treatment received and to differentiate the costs by age of patients.

METHODS

Data were obtained from the databases of national health insurance offices. Persons who had been in a hospital or visited a doctor because of asthma and who also purchased anti-asthmatic drugs during 1997 were identified. The bills of all direct costs of health insurance for each asthma patient could thus be summarised. The data on all purchases of drugs were used to follow the patterns of drug treatment of asthma.

RESULTS

The mean annual treatment costs of one asthma patient were 118 EUR. The costs of hospital care accounted for 27%, costs of ambulatory care for 20% and costs of pharmacotherapy for 53% of all treatment costs. Beta-agonists and corticosteroids for inhalation accounted for more than 80% of prescriptions and 90% of pharmacotherapy costs in patients under 45 years. The users of oral corticosteroids had twice as high per capita annual asthma treatment costs as compared to non-users.

CONCLUSIONS

The frequency of out-patient visits, hospital admissions, number of prescriptions, total costs and costs of pharmaceuticals increased in parallel with age. The total estimated direct costs of asthma diagnosis and treatment during 1997, as extrapolated from the study population, were 2.1 million EUR, and accounted for 1.4% of direct health care costs in Estonia.

Multiple linear eccrine spiradenomas with eyelid involvement

Eccrine spiradenoma is an uncommon tumour of the sweat gland and usually occurs as a solitary small painful nodule. Very rarely, it may present as multiple tumours arranged in a linear/zosteriform fashion. We present the case of a 23-year-old female who had multiple spiradenomas arranged linearly from the midline of forehead to the left corner of the mouth and a few lesions also on the margin of the left eyelid. The lesions were probably along the Blaschko's lines. Tumours were excised surgically in stages. Literature search revealed only 13 reported cases of linear/zosteriform/naevoid multiple spiradenomas and only four cases of solitary spiradenoma of the eyelid. The review of reported cases suggests that arrangement of tumours in a linear/zosteriform pattern is an important diagnostic clue for multiple (naevoid) spiradenomas.

Gas chromatographic determination of 1,4-dioxane at low parts-per-million levels in glycols

1,4-Dioxane is a flammable liquid and tends to form explosive peroxides. Its formation in glycols (low parts-per-million levels), which are used as dehumidifying agents in refineries, may take place by condensation. 1,4-Dioxane thus formed gets distilled over with benzene in the refinery process. Therefore, it is necessary to identify and determine the levels of 1,4-dioxane in glycols as well as benzene. Gas chromatography (GC) is probably the best technique for this purpose. GC analysis may be carried out using a flame ionization detector. Results show that 1,4-dioxane can be comfortably determined down to 2 ppm in glycols and benzene.