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Handa S, Youness M, Keith DA, Rosén A. Persistent pain after total temporomandibular joint replacement surgery: clinical characteristics, comorbidities, and risk factors. Int J Oral Maxillofac Surg 2025; 54:166-173. [PMID: 39237445 DOI: 10.1016/j.ijom.2024.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 08/21/2024] [Accepted: 08/22/2024] [Indexed: 09/07/2024]
Abstract
Chronic post-surgical pain (CPSP) after temporomandibular joint (TMJ) surgery is an under-recognized problem. The aim of this study was to document the characteristics of CPSP and identify patient risk factors and comorbidities associated with the development of CPSP after total TMJ replacement (TJR). This was a retrospective cohort study of patients who underwent TJR between 2000 and 2018 at Massachusetts General Hospital, Boston, USA. The primary outcome was the presence of CPSP and use of pain medications after TJR. The secondary outcome was the risk factors associated with the development of CPSP. A total 88 patients were included (79 females, 9 males). The mean follow-up was 4.2 years. Overall, 68 (77.3%) had CPSP and 20 (22.7%) had no CPSP. Of those with CPSP, 32.4% had severe pain and 45.6% continued to take pain medications. Of the 27 patients with data available on the characteristics of the pain, the majority had myofascial pain, while some developed neuropathic pain. A significant difference was noted between the CPSP and non-CPSP groups in terms of preoperative pain, smoking behavior, and use of opioids, non-steroidal anti-inflammatory drugs, muscle relaxants, and neuropathic pain medications.
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Kumar V, De D, Gupta S, Narayan R V, Mahajan R, Chatterjee D, Handa S. Use of multivariant enzyme-linked immunosorbent assay (ELISA) in the diagnosis of autoimmune bullous disorders in a resource-limited setting: A single-center experience. Indian J Dermatol Venereol Leprol 2024; 0:1-6. [PMID: 39635793 DOI: 10.25259/ijdvl_1195_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 04/19/2024] [Indexed: 12/07/2024]
Abstract
Background Autoimmune blistering disorders (AIBD) result from the formation of auto-antibodies against adhesion proteins of the skin/mucosa(e). These auto-antibodies can be detected in the bound form in the tissue using direct immunofluorescence (DIF) or blood circulation using enzyme-linked immunosorbent assay (ELISA) or other methods. Objectives The objective of this study was to evaluate the concordance rate between the results of multivariant ELISA and the diagnosis of AIBD made using DIF and histopathology in an appropriate clinical context. Methods This was a retrospective study (December 2020 to April 2023) in which the multivariant ELISA assay (able to detect antibodies against desmoglein 1, desmoglein 3, BP180, BP230, envoplakin, and collagen VII) data were retrieved from the dermatology laboratory. Corresponding clinical and histopathology data were searched from relevant institutional databases. As per routine practice, the final diagnosis was assigned based on the clinical presentation, histopathology features and corresponding DIF report. Results After screening the records of 338 patients during the study period, 253 patients were included. Of them, 194 had AIBD and 59 had non-AIBD. In the autoimmune blistering disorder group, 122 and 72 patients had pemphigus and pemphigoid, respectively. Overall, a good level of agreement was found between multivariant ELISA results and the final diagnosis (Fleiss kappa = 0.631, p-value < 0.001). The pemphigus vulgaris group exhibited good agreement (kappa = 0.796, p < 0.001), while pemphigus foliaceous, bullous pemphigoid and non-autoimmune blistering disorders demonstrated moderate agreement (kappa = 0.641, 0.651, 0.533, respectively; p < 0.001). The mucous membrane pemphigoid group had a fair agreement (kappa = 0.289; p < 0.001). Limitations The limitations for the study were its retrospective design, fewer number of patients in certain groups like paraneoplastic pemphigus and gold-standard single antigen specific ELISA was not done. Conclusion Considering good agreement between the multivariant ELISA and the gold-standard diagnosis (clinical findings plus histopathology plus DIF), multivariant ELISA can be used for the diagnosis of AIBDs in places where facilities for DIF are unavailable. Multivariant ELISA can improve etiological diagnosis for a set of autoimmune blistering disorders whose target antigens are represented in the multivariant panel.
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Sharma A, Baskaran N, Chatterjee D, Handa S. Purpuric paradigm: Multiple purpuric lesions on palms. Indian J Dermatol Venereol Leprol 2024; 0:1-3. [PMID: 39635801 DOI: 10.25259/ijdvl_478_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 09/02/2024] [Indexed: 12/07/2024]
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Dogra S, Kumar S, Narang T, Mehta H, Hanumanthu V, Handa S. Efficacy and safety of weekend cyclosporine treatment as maintenance therapy for preventing frequent disease exacerbations in moderate to severe chronic plaque psoriasis patients - A retrospective cohort study. Indian J Dermatol Venereol Leprol 2024; 90:707-712. [PMID: 38841924 DOI: 10.25259/ijdvl_1089_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 02/15/2024] [Indexed: 06/07/2024]
Abstract
Background Psoriasis is a chronic, inflammatory, systemic disease with predominant manifestations in the skin and joints impairing patient's quality of life. A proportion of patients have frequent severe disease exacerbations requiring repeated systemic treatments. There is a scarcity of literature evaluating the role of systemic maintenance therapy in psoriasis patients in preventing such frequent disease flares. Objective To evaluate the efficacy and safety of weekend cyclosporine treatment (WCT) as maintenance therapy in moderate to severe chronic plaque psoriasis patients for the prevention of frequent disease exacerbations. Methods In this retrospective cohort study, 22 psoriasis patients with a history of frequent disease exacerbations (≥ 3 in the last 1 year) who were administered WCT (group A) were compared with the same number of matched patients (age and gender) not on WCT or any systemic maintenance therapy (group B). Results Four patients (18.2%) in group A had disease exacerbations which was significantly lower (p = 0.00, Fisher's exact test) as compared to 21 patients (95.5%) in group B during the study period. Also, patients in group A had significantly lower number of overall exacerbations [mean ± SD: 0.23 ± 0.53 vs 2.95 ± 1.43) p = 0.00, Mann-Whitney U test] as compared to group B. Four (9.1%) patients in group A encountered adverse effects (acneiform eruptions - two, mild gingival hyperplasia - one, myalgia - one) as compared to three (acneiform eruptions - two, headache - one) in group B (p = 1.00). Conclusion WCT significantly reduced the number of disease exacerbations and is a safe and effective mode of maintenance therapy in such subset of psoriasis patients.
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De D, Baskaran N, Thakur V, Hanumanthu VH, Bakshi S, Bhandari S, Katoch D, Handa S. A Clinicodemographic Study of Indian Patients with Hidradenitis Suppurativa and its Association with Metabolic Syndrome. Indian Dermatol Online J 2024; 15:963-970. [PMID: 39640442 PMCID: PMC11616909 DOI: 10.4103/idoj.idoj_330_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/12/2024] [Accepted: 07/26/2024] [Indexed: 12/07/2024] Open
Abstract
Background Hidradenitis suppurativa (HS) is a chronic inflammatory disorder affecting pilosebaceous units causing painful nodules, abscesses, and scarring. Despite global studies linking HS to metabolic syndrome, insights specific to Indian patients are limited. Materials and Methods This study aimed to describe the clinicodemographic characteristics and study frequency of metabolic syndrome in Indian HS patients. In this cross-sectional study, 100 HS patients were evaluated for clinical characteristics, comorbidities, pain and suppuration scores, quality of life, and ophthalmological and dental abnormalities. Metabolic parameters, including anthropometry and blood markers, were performed in all cases and 100 age- and gender-matched controls. Results The mean age was 29.47 years, with a male predominance of 57%. HS predominantly affected a combination of two or more sites (60%), with nodules as primary lesions (95%). Quality of life was significantly impaired, with 49% experiencing moderate impact as per Dermatology Life Quality Index. Metabolic derangements, represented by an increased body mass index, waist circumference, blood pressure, fasting blood sugar, and fasting insulin, were significantly more frequent in HS cases compared to controls (P < 0.001). The frequency of metabolic syndrome in HS patients was 42%, significantly higher than controls (8%, P < 0.001) with a relative risk of 5.25 (95% CI 2.68-10.58). Dental and ophthalmological abnormalities were observed in 35% and 21.7% of screened patients, respectively. Limitations Cross-sectional nature, no prospective assessment to determine evolution with time, and limited patient number are the limitations of the study. Conclusion A substantial association with metabolic syndrome and considerable impact on quality of life is seen in Indian HS patients, emphasizing the need for metabolic screening and holistic management strategies.
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De D, Hanumanthu V, Jinagal J, Handa S, Mahajan R, Chatterjee D, Kumar V, Saikia B, Nahar Saikia U, Dass Radotra B, Minz RW. Clinical and demographic characteristics of mucous membrane pemphigoid in India: A retrospective analysis. Indian J Dermatol Venereol Leprol 2024; 90:763-768. [PMID: 39152854 DOI: 10.25259/ijdvl_273_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 01/07/2024] [Indexed: 08/19/2024]
Abstract
Background Mucous membrane pemphigoid (MMP) is a rare subepidermal autoimmune blistering disorder. The clinical and demographic parameters of this disease in Indian patients have not yet been elucidated in detail. Objective We aimed to study the clinical and demographic characteristics, disease course, and treatment aspects of MMP patients. Methods The data for this study were obtained by reviewing the case record forms of patients registered in the Autoimmune Bullous Disease (AIBD) Clinic of the Department of Dermatology, Venereology & Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, a tertiary care centre in India. The diagnosis of MMP was established on the basis of clinical and immune-histopathological features which are consistent with standard diagnostic criteria for the disease. Results A total of 52 patients with MMP registered in the AIBD clinic were included. The mean age at disease onset was 50 years and the average age at presentation was 56 years. Females outnumbered males in the study with a ratio of 1.36:1. The oral and ocular mucosae were the most commonly affected sites (82.6% and 63.4% respectively). Visual difficulty was reported by half the patients (26 of 52 patients). IgG, C3, and IgA deposits were detected on direct immunofluorescence (DIF) in 29, 21, and 11 patients, respectively. Serologic analysis was performed in only 7 of the patients and of these, just 1 exhibited a positive result on multivariant ELISA and epidermal pattern of binding on salt split skin indirect immunofluorescence. Most patients were treated with prednisolone (44 of 52). Steroid-sparing adjuvants were used in combination including cyclophosphamide, azathioprine, methotrexate, dapsone, and colchicine. Rituximab was administered in 7 patients with severe or refractory disease. Limitations This is a retrospective analysis of data available from a clinic registry. In patients with negative direct immunofluorescence on biopsy, the diagnosis was based on clinico-pathologic consensus. Conclusion MMP is not as uncommon in India as the paucity of reports suggest. Visual complications are frequent in Indian MMP patients. A high index of suspicion is required for early diagnosis and appropriate treatment to prevent ocular complications.
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Chen JE, Handa S, Rosén A, Keith DA, Guastaldi FPS. Animal models of temporomandibular joint heterotopic ossification: a scoping review. Int J Oral Maxillofac Surg 2024; 53:950-960. [PMID: 39089958 DOI: 10.1016/j.ijom.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 06/04/2024] [Accepted: 07/12/2024] [Indexed: 08/04/2024]
Abstract
There are few animal models for heterotopic ossification of the temporomandibular joint (TMJ-HO). This scoping review provides an overview of current knowledge on the induction methods and specific conditions required to produce TMJ-HO in various animal models. Two independent reviewers selected papers from the PubMed, Web of Science, and Cochrane Library databases. The inclusion criteria were articles in English, in vivo studies, and a TMJ-HO induction method. Observational, in vitro, human studies, reviews, and book chapters were excluded. Twenty-four publications were included. HO was surgically, genetically, or chemically induced through single or combined defects in the condyle, articular disc, and temporal bone in animal models (sheep=9 studies, mouse=5, rat=4, rabbit=2, pig=2, goat=1, dog=1, monkey=1) specific for traumatic TMJ-HO (n=4), ankylosis (n=9), osteoarthritis (n=8), experimental disc perforation (n=1), status post-TMJ replacement (n=1), and status post bilateral sagittal split osteotomy (n=1). TMJ-HO remains challenging to study due to its multifactorial etiology and largely unknown pathogenesis, which varies between species. There is a need for more accurate, reproducible animal models that can be extrapolated to human TMJ-HO and a consolidated clinical classification system to allow for meaningful future research.
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Malhi K, Singh S, Chatterjee D, De D, Handa S, Mahajan R. Disseminated verrucous and keratotic plaques in a young boy. Clin Exp Dermatol 2024; 49:1269-1271. [PMID: 38739692 DOI: 10.1093/ced/llae191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024]
Abstract
We present a rare case of verrucous discoid lupus erythematosus in a paediatric patient, with a focus on clinical and histopathological features. We discuss the differential diagnoses, including papulonecrotic tuberculid, verrucous psoriasis and pityriasis rubra pilaris, with a focus on histopathological clues for differentiation, and emphasize the pivotal role of histopathological examination and direct immunofluorescence in confirming the diagnosis.
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Gupta S, Handa S, Chatterjee D, De D, Mahajan R. Extensive Extragenital Lichen Sclerosus-Like Lesions in a Patient with Junctional Epidermolysis Bullosa. Indian Dermatol Online J 2024; 15:834-836. [PMID: 39359296 PMCID: PMC11444457 DOI: 10.4103/idoj.idoj_503_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 01/06/2024] [Accepted: 01/21/2024] [Indexed: 10/04/2024] Open
Abstract
Epidermolysis bullosa (EB) is a heterogeneous group of genetic disorders characterized by the formation of blisters either spontaneously or at the sites of trauma. These heal with post-inflammatory hypopigmentation, scarring, or milia formation. We hereby present a child who presented with widespread hypopigmented atrophic areas, blistering at trauma-prone sites, and nail dystrophy. The significance of this particular case lies in the challenge of distinguishing between epidermolysis bullosa and bullous extragenital lichen sclerosus et atrophicus.
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De D, Shah S, Mahajan R, Handa S. Pemphigus and Pregnancy. Indian Dermatol Online J 2024; 15:749-757. [PMID: 39359288 PMCID: PMC11444454 DOI: 10.4103/idoj.idoj_632_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/21/2023] [Accepted: 10/01/2023] [Indexed: 10/04/2024] Open
Abstract
Pemphigus in pregnancy is a special clinical scenario that has potential consequences on both maternal and fetal outcomes. Being an autoimmune disease with Th2 preponderance, pemphigus is expected to flare in pregnancy, especially in the first two trimesters. Fetal outcomes like stillbirth and neonatal pemphigus have been reported, the latter being a consequence of a transient transplacental transfer of autoantibodies. Management needs to be individualized keeping the risk/benefit ratios of therapies in mind while optimizing maternal and fetal health. It is crucial to have appropriate counseling regarding conception for women with pemphigus in the child-bearing period because the probability of adverse materno-fetal outcomes is higher if the disease is severe.
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Mehta H, Bishnoi A, Singh C, Rajasekaran S, Chatterjee D, Kumaran MS, Handa S. A woman with leonine facies and monoclonal gammopathy. Clin Exp Dermatol 2024; 49:1094-1096. [PMID: 38619049 DOI: 10.1093/ced/llae136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/01/2024] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
A 32-year-old woman presented with a 3-year history of progressive skin thickening. On examination, the skin of the glabella was thickened with longitudinal furrows, resulting in leonine facies. Skin-coloured to reddish-brown, firm, waxy, closely spaced papules partially coalescing to form sheets of induration with circular punched-out areas of sparing in between over the face, neck, trunk, abdomen, arms and thighs were seen. She additionally complained of a tingling sensation and occasional pain over the lateral side of her hands. Punch biopsy obtained from a papule over the nape of the neck revealed fibroblast proliferation with collagen and mucin deposition in the upper and midreticular dermis.
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Singh S, Chatterjee D, De D, Mahajan R, Handa S. Solitary verrucous plaque on a leg. Int J Dermatol 2024. [PMID: 39160649 DOI: 10.1111/ijd.17449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/30/2024] [Accepted: 08/06/2024] [Indexed: 08/21/2024]
Abstract
We present the case of a female in her 70s who presented with a solitary verrucous plaque on her left leg accompanied by painful oral erosions. Various differential diagnoses were considered, like lichen simplex chronicus, hypertrophic lichen planus, and chromoblastomycosis. We diagnosed pemphigus vegetans (PVeg) on a nonintertriginous site through comprehensive clinical examination and histopathological and immunopathological evaluations. This case highlights the importance of considering PVeg in the differential diagnosis of solitary verrucous plaques, even in atypical extra-flexural anatomical locations.
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Kumar A, Jamwal M, Gupta S, Sharma R, Singh N, Kaushal L, Kumar S, Kumar V, Behera B, De D, Handa S, Nahar U, Chatterjee D, Das R, Mahajan R. Molecular profiling of an Indian EB cohort - a single centre experience. Clin Exp Dermatol 2024:llae325. [PMID: 39141798 DOI: 10.1093/ced/llae325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 07/17/2024] [Accepted: 08/09/2024] [Indexed: 08/16/2024]
Abstract
INTRODUCTION Epidermolysis bullosa (EB) encompasses rare hereditary skin conditions marked by skin fragility, nail dystrophy, and minor trauma-induced skin blisters. This study aims to identify genetic variants in Indian EB patients and examine the relationship between genotypic and phenotypic manifestations. MATERIAL AND METHOD EB patients seen consecutively over a period of 5 years at Outpatient Department of Dermatology. Baseline demographic data, birth history, family history, skin manifestation at birth, past medical history, current cutaneous manifestations, and the evolution of the disease were assessed and recorded. Genetic variants were identified using targeted gene panel sequencing of 23 EB-related genes, and a genetic-phenotype analysis was performed. RESULTS Our study included 65 patients with EB. Among 65 EB patients, 38 dystrophic EB cases (58.46%), 12 junctional EB (18.46%), 12 epidermolysis bullosa simplex (18.46%), and 3 Kindler EB (4.62%) were reported. Dominant and recessive forms of dystrophic EB accounted for 16.92% and 41.4%, respectively. We identified 75 unique genetic variants, 58.67% newly discovered and 41.33% previously reported. Compound heterozygous variations were more frequent (55.55%) than homozygous ones (44.44%) in recessive dystrophic EB patients. Junctional EB patients harboured LAMB3 gene mutations more frequently, while epidermolysis bullosa simplex patients showed KRT5 and KRT14 gene missense heterozygous mutations. Kindler EB patients had homozygous mutations in the FERTM1 gene. CONCLUSION Our study unveiled several novel genetic variants; severe phenotypes associated with nonsense genetic variants. These findings offer valuable insights for future clinical assessments and tailored management strategies.
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Handa S, Mehta H, Bishnoi A, Raj D, De D. Efficacy and safety of azathioprine versus mycophenolate mofetil in chronic actinic dermatitis in skin of color: results of a randomized controlled trial. Int J Dermatol 2024. [PMID: 39092474 DOI: 10.1111/ijd.17412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/06/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Chronic actinic dermatitis (CAD) is an immunologically mediated photodermatosis that has been effectively treated with azathioprine and mycophenolate mofetil (MMF) in uncontrolled studies. We conducted a prospective randomized controlled trial to compare the efficacy and safety of azathioprine and MMF in CAD treatment, aiming to address existing evidence gaps. MATERIALS AND METHODS Consecutive CAD patients were randomized into two groups: azathioprine (Group A) or MMF (Group B) for 12 weeks. Primary outcomes included Eczema Area and Severity Index (EASI) and Dermatology Life Quality Index (DLQI) at baseline and Week 12. Secondary outcomes included various clinicodemographic factors predictive of treatment response, defined at least a 75% reduction in EASI score (EASI75) by Week 12. RESULTS The median (IQR) percentage reduction in EASI at 12 weeks was higher in Group B than in Group A [78.3% (75.0-83.30%) vs. 68.3% (31.2-80.10%), P = 0.034]. Baseline DLQI scores indicated a moderate impact on quality of life, with significant reductions by Week 12 in both groups and no intergroup differences at baseline (P = 0.291) or Week 12 (P = 0.599). Overall, 23 patients were classified as non-responders, with more extended illness duration (P = 0.026) and outdoor occupations (P = 0.042) associated with poorer responses. Adverse effects were consistent with known profiles, with one patient discontinuing azathioprine due to hypersensitivity. CONCLUSION Our study highlights the efficacy and safety of azathioprine and MMF in CAD treatment, with MMF showing superior outcomes. However, further research is warranted to explore emerging therapies and prognostic factors in CAD management.
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Shaw D, Dogra S, Singh S, Shah S, Narang T, Kaur H, Walia K, Ghosh A, Handa S, Chakrabarti A, Rudramurthy SM. Prolonged treatment of dermatophytosis caused by Trichophyton indotinea with terbinafine or itraconazole impacts better outcomes irrespective of mutation in the squalene epoxidase gene. Mycoses 2024; 67:e13778. [PMID: 39086026 DOI: 10.1111/myc.13778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Over the past decades, the increasing incidence of recurrent dermatophytosis associated with terbinafine-resistant Trichophyton has posed a serious challenge in management of dermatophytosis. Independent reports of failure of treatment and high minimum inhibitory concentrations (MIC) of antifungals are available, but data correlating MIC and clinical outcomes is still sparse. Therefore, the present study was conducted to evaluate the outcomes of systemic treatment of dermatophytosis and its correlation with MIC of the etiological agents isolated from such patients. METHODS Retrospective analysis of 587 consecutive patients with dermatophytosis was done from March 2017 to March 2019. Demographic and clinical details of the patients were noted, along with the results of direct microscopy and fungal culture. The isolates were identified by sequencing the internal transcribed spacer region of rDNA. Antifungal susceptibility testing was performed following the CLSI M38 protocol. Mutation in the squalene epoxidase (SE) gene was detected by DNA sequencing and ARMS-PCR. Based on the culture-positivity and prescribed systemic antifungal, patients were categorised into Group I culture-positive cases treated with systemic terbinafine and Group II culture-positive cases treated with systemic itraconazole, each for a total period of 12 weeks. RESULTS In the present study, 477 (81.39%) were culture-positive; however, 12 weeks follow-up was available for 294 patients (Group I-157 and Group II-137) who were included for statistical analysis. In both groups [Group I-37/63 (51.4%) and Group II-14/54 (58.3%)], a better cure rate was observed if the initiation of therapy was performed within <6 months of illness. Treatment outcome revealed that if therapy was extended for 8-12 weeks, the odds of cure rate are significantly better (p < .001) with either itraconazole (Odd Ratio-15.5) or terbinafine (Odd Ratio-4.34). Higher MICs for terbinafine were noted in 41 cases (cured-18 and uncured-23) in Group I and 39 cases (cured-16 and uncured-23) in Group II. From cured (Group I-17/18; 94.4% and Group II-14/16; 87.5%) and uncured (Group I-20/23; 86.9% and Group II-21/23; 91.3%) cases had F397L mutation in the SE gene. No significant difference in cure rate was observed in patients with Trichophyton spp. having terbinafine MIC ≥ 1or <1 μg/mL (Group I-p = .712 and Group II-p = .69). CONCLUSION This study revealed that prolonging terbinafine or itraconazole therapy for beyond 8 weeks rather than the standard 4 weeks significantly increases the cure rate. Moreover, no correlation has been observed between antifungal susceptibility and clinical outcomes. The MIC remains the primary parameter for defining antifungal activity and predicting the potency of antifungal agents against specific fungi. However, predicting therapeutic success based solely on the MIC of a fungal strain is not always reliable, as studies have shown a poor correlation between in vitro data and in vivo outcomes. To address this issue, further correlation of antifungal susceptibility testing (AFST) data with clinical outcomes and therapeutic drug monitoring is needed. It also highlights that initiation of the treatment within <6 months of illness increases cure rates and reduces recurrence. Extensive research is warranted to establish a better treatment regime for dermatophytosis.
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Mahajan R, Baskaran N, Kumar S, Behera B, De D, Sarkar R, Handa S. Creating the Indian Association of Dermatologists, Venereologists, and Leprologists (IADVL) Cutaneous Rare Disease Registry (I-CuReD): a 1-year experience. Int J Dermatol 2024; 63:e182-e184. [PMID: 38876478 DOI: 10.1111/ijd.17315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/16/2024]
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Jinagal J, Gupta B, Hanumanthu V, Chatterjee D, Limbu S, Malhotra C, Gupta A, Jain AK, Yangzes S, Mahajan R, Handa S, Pandav SS, De D. Ocular Cicatricial Pemphigoid in Young Patients. Cornea 2024; 43:1015-1021. [PMID: 38692674 DOI: 10.1097/ico.0000000000003547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/02/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE The purpose of this study is to report ocular cicatricial pemphigoid (OCP) occurring in young patients. Relevant literature is also reviewed. METHODS Medical records of patients aged 30 years or younger who were treated for OCP between August 2021 and May 2023 at a tertiary care eye institute were reviewed. The most common differential diagnoses of cicatrizing conjunctivitis, such as Stevens-Johnson syndrome sequelae, chemical injury, chronic topical/systemic drug use, autoimmune connective tissue disorders, or allergic eye diseases, were ruled out based on clinical history, examination, and the Cicatrizing Conjunctivitis Score described by Shanbhag et al. The diagnosis of OCP was confirmed by positive direct immunofluorescence of oral mucosal and/or conjunctival biopsy in a majority of the patients. RESULTS Seven patients fulfilled the criteria for a diagnosis of OCP. The mean age at presentation was 21.86 ± 5.25 years (13-28 years). Some of the patients presented with relatively atypical features for OCP such as corneal immune ring infiltrate and bilateral corneal perforation. Six patients exhibited systemic mucosal lesions, and the direct immunofluorescence yield was 85.71%. All patients required aggressive immunosuppressive treatment. CONCLUSIONS OCP is classically described as a rare disease that occurs in old age. This case series highlights the importance of a higher index of suspicion for diagnosing OCP at a younger age. Early administration of immunosuppressive agents can potentially control severe ocular surface inflammation and its sequelae.
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Malhi K, Chatterjee D, Mahajan R, Handa S, De D. Direct immunofluorescence on plucked hair outer root sheath can predict relapse in pemphigus vulgaris. Int J Dermatol 2024. [PMID: 39086016 DOI: 10.1111/ijd.17405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/11/2024] [Accepted: 07/12/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Prospective research is lacking on the utility of plucked hair outer root sheath direct immunofluorescence (ORS DIF) in the prediction of relapse in pemphigus vulgaris (PV) and the correlation of ORS DIF positivity with serum desmoglein antibody titers. METHODS We performed a prospective cohort study enrolling 80 PV patients in complete clinical remission at a tertiary care center in North India. Study participants underwent ORS DIF at baseline, which was repeated every 3 months. Skin biopsy DIF was done at study inclusion, repeated at 3 months, and upon clinical relapse. An antidesmoglein antibody titer was assessed concurrently with ORS DIF in a subset of patients. Patients on adjuvant therapy had their adjuvant therapy withdrawn either at the initial visit, at 3 months, or at a 6-month follow-up. Our objectives were to determine the association between positive ORS DIF and clinical relapse, the correlation between positive ORS DIF and skin biopsy DIF, and between positive ORS DIF and positive antidesmoglein antibody titers (when concurrently done). RESULTS Twenty-two patients (27.5%) had a clinical relapse. Baseline immunological markers significantly associated with relapse are ORS DIF positivity with IgG (16/36 [45.44%] P = 0.005) and C3 (12/29 [41.37%] P = 0.047) and greater intensity of baseline IgG and C3 positivity in ORS DIF (IgG, P = 0.002; C3, P = 0.033). Notably, a significant correlation was observed between baseline positive ORS DIF and skin biopsy DIF (IgG, ρ = 0.695; C3, ρ = 0.498). Positive ORS DIF strongly correlated with positive anti-Dsg3 antibody titers (φs = 0.815; P < 0.01). Early withdrawal of adjuvant immunosuppressant (within 3 months) (P = 0.007) and positive ORS DIF were also associated with relapse (P = 0.017). CONCLUSION AND RELEVANCE ORS DIF is a reliable predictor of PV clinical relapse and demonstrated robust correlations with skin biopsy DIF and antidesmoglein antibody titers. Periodic assessment of ORS DIF aids in determining new-onset positivity that heralds clinical relapse.
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Sharma A, Parkhi M, Chhabra S, Narang T, Handa S, Dogra S. A challenging case of borderline lepromatous leprosy non-responsive to WHO-MDT: exploring approaches beyond WHO-MDT. Trans R Soc Trop Med Hyg 2024; 118:477-479. [PMID: 38695179 DOI: 10.1093/trstmh/trae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/31/2024] [Accepted: 04/13/2024] [Indexed: 07/06/2024] Open
Abstract
Just as we prioritize personalized medicine for various other medical conditions, we should also include a neglected disease like leprosy, ensuring that patients receive the best care possible and improving their quality of life. Our case highlights the importance of instituting an alternate therapeutic regimen in a scenario where there is a lack of clinical response to multidrug therapy, even in the absence of documented drug resistance of the currently available molecular diagnostics. The search for the perfect regimen tailored for each individual leprosy patient should continue. Alternate anti-leprosy therapy is highly useful in cases with confirmed drug resistance or clinically non-responsive cases; however, their misuse should also be strictly avoided to prevent the development of resistance to them.
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Thakur V, Narang T, Bishnoi A, Dhawan G, Sharma A, Saikia UN, Razmi TM, Dogra S, Handa S, Modi M. Changes in the Cutaneous Nerve Fiber Staining and Distribution of PGP9.5 in Clinically Uninvolved Skin in Leprosy Patients after Completion of Multidrug Therapy and Assessing PGP9.5 as a Marker of Treatment Response. Indian Dermatol Online J 2024; 15:599-604. [PMID: 39050073 PMCID: PMC11265736 DOI: 10.4103/idoj.idoj_233_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 03/07/2024] [Accepted: 04/05/2024] [Indexed: 07/27/2024] Open
Abstract
Background Subclinical involvement of nerves may sometimes be present much before the overt clinical manifestations become apparent. Protein gene product (PGP) 9.5, a ubiquitin-C-terminal hydrolase, has been widely used as a marker to study the involvement of peripheral nerve fibers in many diseases. Aim and Objectives To evaluate the change in cutaneous nerve fiber staining and distribution from pre-treatment and post completion of multidrug therapy through the expression of PGP9.5 and to assess PGP9.5 as a marker of treatment response. Materials and Methods In this prospective single-center observational study, skin biopsy was taken in patients with leprosy, having areas of nerve function impairment (NFI), based on findings of nerve conduction studies (NCSs), but not having lesions or impaired tactile or thermal impairment clinically. The thin nerve fiber density in the clinically normal skin in areas supplied by nerve showing changes of sensory neuropathy was evaluated to study the density of the fibers. A second biopsy was taken at the end of treatment from a site near the previous site to assess the changes in intra-epidermal nerve fiber staining and distribution. Results Thirty-three patients were recruited in the present study (24 males and 9 females). Pre-treatment, 27 patients had abnormal NCSs, while six patients did not have any evidence of neuropathy on NCSs. Staining for nerve fibers using PGP9.5; in the epidermis was positive in five patients pre-treatment and 11 patients post treatment (P = 0.181). Staining in the dermis revealed positivity in 14 pre-treatment, which increased to 18 post treatment (P = 0.342). Adnexae showed positivity in five patients pre-treatment and increased to 17 post treatment (P = 0.005). Conclusion A reduced PGP9.5 staining in the epidermal, dermal, and adnexal regions was seen in leprosy patients, which improved post treatment. Thus, PGP9.5 may serve as a marker of NFI and treatment response.
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Baskaran N, Mustari A, Malhi K, Bishnoi A, De D, Handa S, Chatterjee D, Mahajan R. Co-occurring livedoid vasculopathy and limited cutaneous systemic sclerosis associated gangrene successfully managed with alprostadil and aspirin. Indian J Dermatol Venereol Leprol 2024; 0:1-3. [PMID: 39152888 DOI: 10.25259/ijdvl_89_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/05/2024] [Indexed: 08/19/2024]
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Malhi K, Mustari A, Singh S, Kumar A, Vignesh P, De D, Handa S, Mahajan R. A photo-distributed rash and eczematous eruptions in two siblings-A diagnostic conundrum. Australas J Dermatol 2024; 65:402-405. [PMID: 38646889 DOI: 10.1111/ajd.14295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 04/23/2024]
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Mehta H, Narang T, Dogra S, Handa S, Hatwal J, Batta A. Cardiovascular Considerations and Implications for Treatment in Psoriasis: An Updated Review. Vasc Health Risk Manag 2024; 20:215-229. [PMID: 38745849 PMCID: PMC11093123 DOI: 10.2147/vhrm.s464471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/02/2024] [Indexed: 05/16/2024] Open
Abstract
Psoriasis, a prevalent chronic inflammatory skin disorder affecting 2-3% of the global population, has transcended its dermatological confines, revealing a profound association with cardiovascular diseases (CVD). This comprehensive review explores the intricate interplay between psoriasis and cardiovascular system, delving into genetic links, immune pathways, and adipose tissue dysfunction beyond conventional CVD risk factors. The pathophysiological connections unveil unique signatures, distinct from other inflammatory skin conditions, in particular psoriasis-specific genetic polymorphisms in IL-23 and TNF-α have consistently been linked to CVD. The review navigates the complex landscape of psoriasis treatments, addressing challenges and future directions in particular relevance to CVDs in psoriasis. Therapeutic interventions, including TNF inhibitors (TNFi), present promise in reducing cardiovascular risks, and methotrexate could constitute a favourable choice. Conversely, the relationship between IL-12/23 inhibitors and cardiovascular risk remains uncertain, while recent evidence indicates that Janus kinase inhibitors may not carry CVD risks. Emerging evidence supports the safety and efficacy of IL-17 and IL-23 inhibitors in patients with CVDs, hinting at evolving therapeutic paradigms. Lifestyle modifications, statins, and emerging therapies offer preventive strategies. Dedicated screening guidelines for CVD risk assessment in psoriasis are however lacking. Further, the impact of different disease phenotypes and treatment hierarchies in cardiovascular outcomes remains elusive, demanding ongoing research at the intersection of dermatology, rheumatology, and cardiology. In conclusion, unraveling the intricate connections between psoriasis and CVD provides a foundation for a holistic approach to patient care. Collaboration between specialties, advancements in screening methodologies, and a nuanced understanding of treatment impacts are essential for comprehensive cardiovascular risk management in individuals with psoriasis.
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Naryanan V, Mahajan R, Ashraf R, Sharma A, Lal B, De D, Handa S. Facial Segmental Infantile Haemangioma: A Cutaneous Mosaicism Quandary. Indian J Dermatol 2024; 69:238-240. [PMID: 39119319 PMCID: PMC11305489 DOI: 10.4103/ijd.ijd_1089_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
Mosaicism has long been considered the underlying mechanism of segmental infantile hemangiomas (SIH). This was a prospective pilot case-control study conducted with the objective to quantify the percentage overlap of silhouettes of facial SIH with those of Blaschko lines (the most well studied archetypical pattern of mosaicism on face) as compared to other mosaic disorders on face. Lesional silhouettes of 8 patients with SIH (Group A) and 6 patients with other facial dermatosis known to have blaschkoidal distribution (Group B), were overlapped on a standardized template with Blaschkoidal lines on the frontal view of face. The alignment was done via the auto align tool of Photoshop and the percentage of overlap was calculated with an online image comparison software (IMGonline.com.ua). There was a significant difference in mean overlap in Group A (72.92 ± 15.6 %) as compared to Group B (90.1 ± 4.3%; P=0.018). Hence, we concluded that facial SIH do not follow lines of Blaschko.
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Reddy P, Mahajan R, Mehta H, De D, Bhatia A, Kumar R, Handa S. Increased prevalence of metabolic syndrome and non-alcoholic fatty liver disease in children with atopic dermatitis: A case-control study from northern India. Pediatr Dermatol 2024; 41:421-427. [PMID: 38165012 DOI: 10.1111/pde.15502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/02/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND/OBJECTIVES Atopic dermatitis (AD) is a chronic inflammatory skin disorder that affects children worldwide, with potential associations to metabolic syndrome (MetS) and non-alcoholic fatty liver disease (NAFLD). Limited research exists on the interplay between AD, MetS, and NAFLD in the pediatric population. This study aimed to investigate the prevalence and potential relationships among AD, MetS, and NAFLD in children. METHODS A case-control study design was employed, recruiting 50 children with AD (median age: 9.5 years) and 50 age- and sex-matched healthy controls (median age: 11.5 years, p = .051). Data on demographic characteristics, clinical features, disease severity, treatment history, anthropometric measurements, and laboratory evaluations were collected. MetS and NAFLD were diagnosed based on established criteria. RESULTS The prevalence of MetS was significantly higher in children with AD compared with controls (24% vs. 2%, p = .002). Significant differences for systolic blood pressure (p < .001), diastolic blood pressure (p = .012), and waist circumference (p = .040) were observed between AD patients and controls. Children with AD had higher triglyceride levels (p = .005). NAFLD was exclusively seen in moderate to severe AD cases (6% vs. 0%, p = .242). AD severity showed associations with increased body mass index (p = .020). CONCLUSION This study highlights the increased prevalence of MetS and the potential association with NAFLD in children with AD. The findings suggest that AD may contribute to the development of metabolic abnormalities at an early age. Further research is needed to elucidate the underlying mechanisms and explore preventive strategies for these interconnected conditions.
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