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   Table of Contents - Current issue
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January-June 2018
Volume 38 | Issue 1
Page Nos. 1-51

Online since Monday, March 12, 2018

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ORIGINAL ARTICLES  

Bacillus Calmette-Guerin polysaccharide nucleic acid extract versus triamcinolone acetonide intralesional injection in the treatment of oral lichen planus: a comparative study p. 1
Mohamed I Metwalli, Ayman M Marei, Mohamed A Toama, Mohamed I Soliman, Manal M Fawzy
DOI:10.4103/ejdv.ejdv_12_17  
Background Oral lichen planus (OLP) is a chronic inflammatory disease of unknown etiology and pathogenesis with frequent relapses. OLP has several patterns; some are asymptomatic whereas others may affect patient’s quality of life. Corticosteroids (CS) (either topical, intralesional, or systemic) are the cornerstone in OLP treatment. Unfortunately, CS are associated with variable local and systemic adverse effects; therefore, other therapeutic modalities have been tried for OLP treatment. Among these modalities was the Bacillus Calmette-Guerin polysaccharide nucleic acid extract (BCG-PSN). Aim The aim of this study was to evaluate the efficacy, safety, and recurrence after intralesional BCG-PSN injection in comparison with intralesional triamcinolone acetonide (TA) injection in treatment of OLP. Patients and methods BCG-PSN was extracted from BCG vaccine in the Immunology Research Laboratory, Department of Microbiology and Immunology, Zagazig University. A total of 26 patients with clinically proved OLP were enrolled in the study. They were divided into two groups (group A and group B). Group A included 13 patients with OLP who were treated with two intralesional injections of TA (20 mg/ml) once weekly for 2 weeks. Group B included 13 patients with OLP who were treated with six intralesional injections of BCG-PSN, 0.5 ml every other day for 2 weeks. The responses of OLP lesions to intralesional injection of BCG-PSN and TA were evaluated based on reduction in their surface area. A semiquantitative (reticulation/erythema/ulceration) scoring system was used for monitoring the response of OLP lesions. Pain was assessed using a numerical rating scale. Results No statistically significant differences were found between the groups in the reduction of erosion areas (t=7.10, P=0.47), reticulation/erythema/ulceration scores (t=80.5, P=0.83), and numerical rating scale scores (t=80.0, P=0.81). There was no statistically significant difference between both groups regarding the response to therapy (χ2=1.87, P=0.39). Nonsignificant difference was found in the occurrence of adverse effects between the groups (P=0.500). There was nonsignificant difference in the recurrence rate (77.8 vs. 71.4%, P=0.61) between the two groups. Conclusion Intralesional BCG-PSN injection can be used as an effective alternative to intralesional TA in the treatment of OLP especially in patients resistant to or with contraindications for CS.
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Association of proinflammatory cytokine tumor necrosis factor-α gene promoter -308 and -238 polymorphism with psoriasis in North Indian population p. 12
Wani Aadil, Bashir Ahmad Ganai, Tahseena Akhtar, Tarun Narang, Rajinder Kaur
DOI:10.4103/ejdv.ejdv_23_17  
Background/objective Tumor necrosis factor (TNF) is an important proinflammatory cytokine that plays a role in the pathogenesis of psoriasis. The aim of the present study was to investigate the role of TNF-α −308G/A and TNF-α −238G/A polymorphism, haplotype, and serum level in the pathogenesis of psoriasis. Materials and methods A total of 200 psoriatic patients and 200 controls were genotyped for TNF-α −308G/A and TNF–α −238G/A polymorphism by using polymerase chain reaction. In addition, serum levels of TNF-α were measured by enzyme-linked immunosorbent assay. Results Polymorphism of TNF–α −308 was found to be associated with a decreased risk for psoriasis odds ratio=0.29; (95% confidence interval=0.14–0.62), and polymorphism of TNF–α −238 was associated with an increased risk for psoriasis odds ratio=37.81; (95% confidence interval=12.77–112.01). HT2 GA haplotype was found to be associated with an increased risk for psoriasis. Moreover, the serum TNF-α level increased in patients compared with controls, with a significant correlation between serum TNF-α and psoriasis severity. Conclusion Our findings suggested that TNF-α polymorphisms imparted significant risk toward the development of psoriasis in north Indian population.
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Histopathologic spectrum of reactions to black tattoo pigment: a report of five cases from India p. 18
Gnanapriya Vellaisamy, Rajalakshmi Tirumalae, YK Inchara
DOI:10.4103/ejdv.ejdv_30_17  
There is an increasing prevalence of cutaneous adverse reactions to tattoos. The reactions range from inflammatory, infectious, to neoplastic conditions. Colored tattoo inks are most commonly implicated in such cases. Black tattoo pigment is generally considered inert. We describe a series of five cases of adverse reactions to black tattoo pigment, a rare feature. The age of these patients ranged from 17 to 24 years. There were four men and one woman. The patterns observed were lichenoid, tuberculoid granulomatous, granuloma annulare-like, pseudoepitheliomatous hyperplasia, and minimal dermal infiltrate.
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Role of prolactin in activity of systemic lupus erythematosus p. 23
Mohamed I Soliman, Abdulla M Esawy, Shorook A Khashba
DOI:10.4103/ejdv.ejdv_32_17  
Background Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease that primarily affects young women of reproductive age. The preponderance of SLE in women may result from stimulation of the immune system by female hormones. Prolactin is not only a lactogenic hormone but also an immunomodulator involved in lymphocyte survival activation and proliferation. The aim of this study is to estimate serum prolactin in SLE patients and to determine whether there is any correlation between serum PRL level and activity of SLE disease. Subjects and methods The present study was carried out in Dermatology and Rheumatology outpatient clinics of Zagazig University hospitals. The laboratory investigations were analyzed in Clinical Pathology Department of Zagazig University. Ninety persons of both sexes participated in this study which was carried out between May 2015 and Dec 2016 on 90 subjects divided into two groups: Group A included 45 SLE patients diagnosed according to the American College of Rheumatology (ACR) classification criteria for SLE 4 of 11 criteria for definite case definition (10) and Group B included 45 apparently healthy persons who were age and sex matched and nonrelative to patients as control, SLE patients were divided according to the severity of the disease activity into 4 groups using SLEDAI. Specific investigation Serum PRL was determined by the electrochemiluminescence immunoassay “ECLIA” by using “cobas 411” immunoassay analyzer and Elecsys prolactin II reagent kits. Normal serum PRL range was from 5–20 ng/ml. Results In the present study, serum PRL level in SLE patients ranged from (6–27 ng/ml) with a mean PRL level ± SD of (13 ± 5.6). On the other hand, serum PRL level in the control subjects ranged from (5–20 ng/ml) with a mean PRL level ± SD of (11.8 ± 4.2). The normal range of serum PRL level is 6–20 ng/ml. No statistical significant difference were found between patients and control groups as regards serum PRL level (P > 0.05). There was increase in level of serum prolactin in severe cases of SLE followed by moderate followed by mild with statistically significant difference as P value <0.05. There was statistically significant difference, when comparing serum PRL and patients’ disease activity, as P value <0.05. Conclusions In this study, there was no significant higher serum PRL level in SLE patients than the control group, no significant relationship between serum PRL level and SLEDAI, but a significant relation between serum PRL level and increase the severity of SLEDAI score.
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The relationship between platelet volume and risk of atherosclerosis in patients with psoriasis p. 29
Enas A.M. Mahrous
DOI:10.4103/ejdv.ejdv_36_17  
Objective The aim of this research was to evaluate the relation between the mean platelet volume (MPV) and clinical aspects (onset, duration, and severity) in patients with psoriasis. In addition, the purpose was to evaluate the possible risk of atherosclerosis in these patients. Background Psoriasis is an inflammatory skin disease affecting 2–4% of the world population. However, studies in developing countries have reported higher prevalence rates of ∼4.6% on an average. MPV is an indicator of platelet activation, and it is a newly emerging risk factor for patients with atherothrombotic psoriasis. Patients and methods A case–control study was conducted on 40 patients with variable degrees of psoriasis severity (cases) and they were compared with 20 matched healthy participants (controls). All participants were selected from dermatology inpatients and outpatient clinics of the Menoufia University Hospital in the period from September 2015 to March 2016. Full detailed history, routine laboratory investigations, clinical features, Psoriasis Area and the Severity Index (PASI) scores, and carotid intima-media thickness (CIMT) and nonalcoholic fatty liver disease (NAFLD) values were taken for each participant (cases and controls). Results There were statistically no significant differences between patients with psoriasis and control groups regarding age, sex, BMI, total cholesterol, and triglycerides (P>0.05%, for all), whereas patients with psoriasis had significantly higher systolic and diastolic blood pressure, fasting plasma glucose, mean MPV and CIMT values, and frequency of ultrasound-diagnosed NAFLD than the control group. In addition, BMI, duration of illness, PASI, and mean values of MPV were significantly (P=0.5) elevated in patients with psoriasis with atherosclerosis than patients with psoriasis without atherosclerosis. Moreover, MPV level was correlated positively with age, BMI, duration of psoriasis, PASI score, and CIMT in the atherosclerotic psoriatic case group. Moreover, CIMT and PASI score were correlated positively with BMI, duration of illness, MPV, systolic blood pressure, diastolic blood pressure, glycated hemoglobin, and NAFLD in the psoriasis patient group, whereas CIMT was significantly correlated positively with PASI score. Conclusion Psoriasis is associated with high MPV. So, MPV is a good indicator of psoriasis severity. Thus, MPV is a good positive test for early detection of premature atherosclerosis in patients with psoriasis. This study may confirm previous observation indicating increased platelet activation in psoriasis. Increased platelet activity could contribute toward increasing the atherosclerotic risk in patients with psoriasis.
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Comparison of clinical diagnosis with histopathology in inflammatory skin diseases: a retrospective study of 455 cases p. 37
Seema Umarji, Gayatri Ravikumar, Meryl Antony, Rajalakshmi Tirumalae
DOI:10.4103/ejdv.ejdv_62_16  
Background Skin biopsies are performed to support the clinical diagnosis of inflammatory skin diseases. Clinical information is conveyed to the pathologist as a list of differential diagnosis. Aims The aims of this article are to correlate the clinical diagnosis with histopathologic diagnosis and to determine the correlation rank order of differentials with histopathologic diagnosis. Methods Four hundred and fifty-five skin biopsies signed out as inflammatory lesions were identified using the laboratory information system. Clinical differential diagnosis from the biopsy requisition forms were tabulated and compared with the final histopathologic diagnosis. Results Out of the 455 individuals considered, 237 (52.08%) were men and 218 (47.9%) were women. The clinical diagnosis with more than 40 mentions included vasculitis, lichenoid dermatitis, discoid lupus erythematosus, psoriasis and eczema. The histopathologic diagnosis with more than 20 mentions included lichenoid dermatitis, cutaneous vasculitis, pemphigus vulgaris, psoriasis and Hansen’s disease. The median number of differential diagnosis per patient was 3 (range: 1–5). The final diagnosis was included in the differentials in 412 (90.5%) and absent in 43 (9.5%) cases. In 339/412 (82.3%) cases, the final diagnosis was the first differential. In 70/412 (16.9%) cases, the final diagnosis was listed as the second or third differential and in 3/412 (0.007%) cases as the fourth and fifth. Among the 37 discordant cases where the clinical details were available, the clinical description correlated with the final diagnosis in 15 cases; clinical and histopathologic diagnoses fell under the same broad disease category in 19 cases. Only 3/37 cases were truly discordant. Limitations The sample size and the possibility of lesions being overbiopsied are the only possible limitations. Conclusion The overall concordance between the first three clinical diagnosis and histopathology was a good 98%. A longer list of differential diagnosis is not helpful. In situations where a specific clinical diagnosis is deferred, an accurate description of the lesions aids the pathologist.
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Results of intravenous immunoglobulin use and treatment in the South Province of Turkey p. 42
Hülya Nazik, Mehmet K Mülayim, Perihan Öztürk
DOI:10.4103/ejdv.ejdv_39_17  
Objective In this study, we aimed to evaluate the use of intravenous immunoglobulin (IVIG) in our clinic and investigate the effect of its treatment on diseases in patients with pemphigus. Materials and methods Age, sex, disease, skin biopsy result, duration of illness, treatments received, IVIG adverse effects, and clinical course were recorded by screening medical records of patients with different diagnoses receiving IVIG. The findings were evaluated retrospectively. Findings The total number of cases treated with IVIG was 21. A total of 14 cases were diagnosed as having pemphigus, and three cases were diagnosed as having pyoderma gangrenosum, one (4.8%) case as Sweet syndrome, one (4.8%) case as lichen planus, one (4.8%) case as resistant urticaria, and one (4.8%) case as hyperimmunoglobulin E syndrome. The mean time to start IVIG treatment from diagnosis in patients with pemphigus was 2.62±2.3 years (minimum–maximum: 1–10 years). The mean number of cure IVIG treatment cycles given to patients was 11.38±7.63 (minimum–maximum: 1–30). In patients with pemphigus, a partial remission was achieved with an average cure IVIG treatment cycle of 2.71±3.3 (minimum–maximum: 0–10 cures). In three (21.4%) of the pemphigus cases that received IVIG, the treatment was terminated owing to remission. In pemphigus cases where the treatment was terminated owing to remission, the mean number of IVIG cycles was 12.7±5.9 (minimum–maximum: 6–17). Conclusion IVIG treatment has become a reliable treatment option in our clinic, which is preferred owing to successful treatment results and clinical experience in many different diseases, especially pemphigus.
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CASE REPORT Top

Bilaterally symmetrical terra firma-forme dermatosis: a diagnostic conundrum Highly accessed article p. 46
Chetna Singla, Jyoti Budhwar, Bharat B Mahajan
DOI:10.4103/ejdv.ejdv_35_17  
Terra firma-forme dermatosis or dermatosis neglecta is characterized by dirty brown plaques that can be removed by forceful rubbing or with an alcohol swab. Also known as Duncan’s Dirty Dermatosis, it is usually seen at the regions of the neck, trunk, and upper extremities in children as well as adults. Here we report a patient with complaints of multiple asymptomatic dirty brown-colored, flat-topped slightly raised lesions over the face in a young girl, and emphasize its unique expression. All the lesions completely disappeared with forceful rubbing using a spirit swab, with normal underlying skin without any recurrence till date.
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LETTER TO THE EDITOR Top

Acral acrochordon: an unusual site of presentation p. 49
Pragya A Nair, Rahul Krishna S Kota
DOI:10.4103/ejdv.ejdv_11_17  
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