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Background: Psoriasis is a chronic, inflammatory, relapsing and remitting disease with no cure till date. There is a paucity of trials using a combination of methotrexate (MTX) and cyclosporine (CsA) in chronic plaque psoriasis, due to fear of added toxicity, although they are time tested treatment options for monotherapy. Aims: The study aimed to compare the efficacy and adverse effect profile of the standard recommended dose of MTX (i.e. 0.3mg/kg/week) versus a combination of reduced doses of MTX and CsA (i.e. MTX 0.15 mg/kg/week with CsA 2.5mg/kg/day) in patients with chronic plaque psoriasis. Methods: Study design was a non-blinded randomised controlled trial. Patients of chronic plaque psoriasis with PASI more than 10 were randomised in 1: 1 allocation to receive either 0.3 mg/kg/week of intramuscular MTX injection or a combination of 0.15 mg/kg/week of intramuscular MTX injection and 2.5 mg/kg/day of CsA rounded off to the nearest 25 mg. Patients were followed up at every 2 weeks for 12 weeks. The doses were kept fixed throughout the study period. Results: A total of 66 patients received MTX monotherapy, whereas 67 patients received the combination. At baseline, both groups were comparable in their BSA (P = 0.105, Student t-test) and PASI (P = 0.277, Student t-test), which reduced significantly at 12 weeks in both groups (P < 0.001, paired t-test). The achievement of PASI-75 (P = 0.005), PASI-90 (P < 0.001) and PASI-100 (P = 0.001) was more in the combination group (Chi square test). Intention to treat analysis using Chi square test also showed better outcomes for PASI-75 (P = 0.027), PASI-90 (P < 0.001) and PASI-100 (P = 0.001) in the combination group. Combination group also had earlier onset of action (P = 0.001, Chi square test). There was no significant difference between the groups in terms of laboratory and clinical adverse events. Limitations: Non-blinded, no comparison with CsA monotherapy arm, no follow up beyond 12 weeks. Conclusion: The combination of reduced doses of MTX and CsA is more efficacious with earlier onset of action and similar adverse effects as with MTX monotherapy.

Microbiological safety is very important aspect of blood transfusion services (BTS). Viral infectious agents possess a great risk of transfusion transmitted disease. On the one hand, blood or component transfusion is a lifesaving modality but on the other hand it can cause great mortality or morbidity in recipient if not used judiciously. The main aim of the study is to evaluate the prevalence of HIV, HBV, HCV, Syphilis and Malaria amongst all types of donors donated at blood bank of Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi during the year 2017. This was a retrospective study. The blood donors included in this study include all donors coming directly to blood bank and blood donation camps organized by blood bank. Total donation during that period was 22255 units. A detailed questionnaire was given to the donors for registration. A total of 226 units (1.01%) were seropositive. The sero-prevalence of HIV, HBV, HCV, and Syphilis were 0.9% (21), 0.79% (177), 0.09% (22), 0.02% (6) respectively. No cases of malaria were detected. TTI can be reduced by motivating maximum voluntary blood donation, reducing replacement donation, public information and donor education awareness programme, stringent donor screening criteria and vigilance of error.

BACKGROUND Dermatophytic infections have undergone unprecedented changes in India in the recent past. Clinical trials to find out the effectiveness of the four main oral antifungal drugs are lacking. OBJECTIVES We tested the effectiveness of oral fluconazole, griseofulvin, itraconazole and terbinafine in chronic and chronic relapsing tinea corporis, tinea cruris and tinea faciei in an investigator-initiated, randomized, pragmatic trial. METHODS Two hundred patients with microscopy-confirmed tinea were allocated to four groups (50 patients in each group): fluconazole 5 mg kg-1 per day, griseofulvin 10 mg kg-1 per day, itraconazole 5 mg kg-1 per day and terbinafine 7·5 mg kg-1 per day. Allocation was performed by concealed block randomization and the patients were treated for 8 weeks or until cure. Effectiveness was calculated based on intention-to-treat analysis. The trial was registered with the Clinical Trials Registry India (CTRI/2017/04/008281). RESULTS At 4 weeks, all drugs were similarly ineffective, with cure rates being 8% or less (P = 0·42). At 8 weeks, the numbers of patients cured were as follows: fluconazole 21 (42%), griseofulvin seven (14%), itraconazole 33 (66%) and terbinafine 14 (28%) (P < 0·001). Itraconazole was superior to fluconazole, griseofulvin and terbinafine (adjusted P ≤ 0·048). Relapse rates after 4 and 8 weeks of cure with the four treatments were not different (P ≥ 0·42). Numbers needed to treat (vs. griseofulvin), calculated on the basis of cure rates at 8 weeks, were as follows: fluconazole 4, itraconazole 2 and terbinafine 8. CONCLUSIONS The results show limited effectiveness of all four antifungal drugs. In view of cure rates and the number needed to treat, itraconazole is the most effective drug, followed by fluconazole (daily), terbinafine and then griseofulvin, in chronic and chronic relapsing dermatophytosis in India. What is already known about this topic? Oral antifungal drugs are considered to have a high cure rate in tinea corporis, tinea cruris and tinea faciei. Unprecedented changes have been noticed in the last few years in India in the morphology, course and treatment responsiveness of tinea; however, data about the effectiveness of oral antifungals are lacking. What does this study add? Our results show limited effectiveness of four oral antifungal drugs (fluconazole, griseofulvin, itraconazole and terbinafine) in the current epidemic of altered dermatophytosis in India. Among the four drugs tested, oral itraconazole is the most effective. Linked Comment: Elewski. Br J Dermatol 2020; 183:798-799.

Background: Insulin resistance (IR) is a pre-diabetic condition and has been reported in patients with acanthosis nigricans (AN) and acrochordon. AN and acrochordon are claimed to be cutaneous markers of IR. Aim: The purpose of this paper was to study the association of AN and acrochordon with IR. Methods: It was a cross-sectional hospital-based study. Both groups were assessed for IR by using homeostatic model assessment of insulin resistance (HOMA-IR) formula. Results: A total of 70 cases and an equal number of controls were studied. IR was observed more in cases (41.4%) compared to controls (17.1%) (P < 0.01). Mean HOMA-IR value was also significantly higher in cases (4.32 ± 4.44) compared to controls (2.27 ± 0.90) (P < 0.05). Limitations: Low number of cases and controls were taken in the study. Association with hyperlipidemia and metabolic syndrome was not elicited. Conclusions: AN and acrochordons were found to be associated with IR.

Background: Identification of culprit drug causing adverse cutaneous drug reactions may not be possible clinically due to the intake of more than one drug. Aim: To compare the sensitivity of skin tests with gold standard oral rechallenge test to detect adverse cutaneous drug reactions. Materials and Methods: This is a prospective interventional hospital-based study of patients with adverse cutaneous drug reactions attending the outpatient department of dermatology and venereology at a tertiary care center over a 12-month period. Skin prick tests, intradermal tests, and oral rechallenge tests were performed in these patients and their sensitivities were compared. The data of quantitative nature is presented in mean and standard deviation, and categorical variables are presented in number and percentage. The sensitivity of skin tests is compared with the gold standard oral rechallenge test. Results: A total of 49 patients with adverse cutaneous drug reactions were evaluated. Clinical spectrum of adverse cutaneous drug reactions ranged from mild to severe, with fixed drug eruption being the commonest (55.1%) followed by maculopapular exanthem (32.7%). The highest incidence was with fluoroquinolones (43.8%) followed by nonsteroidal anti-inflammatory drugs. Fluoroquinolones were the major cause of fixed drug eruption followed by nonsteroidal anti-inflammatory drugs. The sensitivity of skin prick test and intradermal tests were 49% and 73%, respectively and the difference was highly significant (P < 0.001). The difference in sensitivity in skin prick test versus oral rechallenge test and intradermal test versus oral rechallenge test was also highly significant (P < 0.001). Limitations: Small sample size was a major limitation. Histopathological examinations and human leukocyte antigen associations could not be done. Conclusion: Predominant causative drugs were fluoroquinolones followed by nonsteroidal anti-inflammatory drugs. Sensitivities of skin prick test and intradermal test were quite good and these skin tests should be performed before oral rechallenge test in cases of adverse cutaneous drug reactions.

Acquired port wine stain though an uncommon entity that develops later in life, resembles congenital port wine stain morphologically and histologically. Congenital port wine stains are vascular lesions caused by progressive ectasia of blood vessels which is located in the vascular plexus of the dermis. Congenital port-wine stains may be associated with Sturge Weber syndrome causing neurological and eye abnormalities such as glaucoma. Here we report a 60-year-old male presenting with a complaint of asymptomatic reddish patches over the nose for 15 years.

Fusarium species are known to cause disseminated cutaneous lesions in immunocompromised patients. Some cases of fusariosis are reported in patients infected with the human immunodeficiency virus. There are two reports in such patients with systemic comorbidities like lymphoma, neutropenia and infective port-a-catheter. Another reported patient had systemic fusariosis, without skin involvement. Diagnosis and treatment of cutaneous fusariosis is difficult and resistance to antifungals is a problem. Our patient was at an advanced human immunodeficiency virus infection stage with disseminated cutaneous fusariosis, without any systemic involvement, who responded completely to oral itraconazole.

Background: Patients with sexually transmitted infections (STIs) suffer not only with the physical problems but also with various psychological problems. Majority of bacterial STIs are treatable in a short period, while viral STIs may persist for longer duration or have frequent recurrences. Aims and Objectives: The aim of the study was To study different aspects of psychological health and well-being in patients with STIs. Materials and Methods: Study design was a prospective cross-sectional hospital-based study. Data were collected during July 2016–April 2018. STIs were divided into four groups (genital herpes, genital warts, and genital discharge and syphilis). One way analysis of variance and Scheffe Test were used for analysis of the data. Results: A total of 410 patients were included in the study. Majority of patients were suffering with genital herpes (139), followed by warts (104), discharge (92), and syphilis (75). Genital herpes and genital warts indicated significantly more cognitive affective (CA) depression as compared to the patients suffering with syphilis. Satisfaction with life was more with genital discharge and syphilis in comparison to the patients with genital warts and genital herpes. Genital herpes showed more perceived stress in comparison to genital discharge. Genital warts indicated more somatic depression as compared to syphilis and genital discharge patients while genital herpes showed more somatic depression than in patients suffering with genital discharge. Genital warts and genital herpes indicated significantly more overall depression as compared to the patients suffering with syphilis. Conclusion: Overall depression was more in patients with genital herpes and warts. The findings provide empirical bases for extended studies on behavioral intervention programs.

Objectives: The objective of this study was to design and evaluate a novel multiplex nested polymerase chain reaction (PCR) protocol for simultaneous detection of Neisseria gonorrhoeae and Chlamydia trachomatis in genitourinary specimens obtained from symptomatic patients clinically suspected of sexually transmitted infections (STIs), targeting two different genes each for these pathogens. Materials and Methods: A total of 116 genitourinary specimens were collected from men (n = 12) and women (n = 104). Direct microscopy, culture isolation, and antimicrobial susceptibility testing for N. gonorrhoeae were performed. Multiplex nested PCR was performed on clinical samples using novel designed primers targeting porA pseudogene and opa gene of N. gonorrhoeae and momp gene and cryptic plasmid of C. trachomatis simultaneously. DNA sequence analysis of nested PCR amplicons for each of four gene targets was carried out for the validation of in-house designed primers and PCR protocol. Results: A total of 51.72% (60/116) patients were detected to have either of the two STIs. About 35.35% (41/116) of patients were positive for C. trachomatis and 33.62% (39/116) for N. gonorrhoeae by employing multiplex nested PCR. Coinfection with N. gonorrhoeae and C. trachomatis was detected in 17.24% (20/116) patients. 31.5% endocervical swabs (n = 54), 64.4% speculum-assisted high vaginal swabs (n = 45), and 80% self-collected vaginal swabs (n = 5) were detected positive for either of two STIs. Conclusions: The multiplex nested PCR protocol designed and employed in the present study may be used in the diagnosis and management of both symptomatic as well as asymptomatic cases of N. gonorrhoeae and C. trachomatis, particularly among high-risk groups.

>Background: WHO MDT is the main drug regimen for treating leprosy and has been used for more than three decades. Many cases of relapse of leprosy have been reported, which points towards the emergence of drug resistance with the antileprotic drugs. >Objectives: To find the resistance with the antileprotic drugs by detecting the mutations in drug resistance determining region of the rpoB, folP1 and gyrA genes of Mycobacterium leprae. Methods: Leprosy patients with bacterial index ≥2 were included in the study. The slides were further processed to extract genomic DNA, and polymerase chain reactions were performed to amplify the drug resistance determining region (DRDR) of rpoB, folP1 and gyrA genes. The samples in which genes could be amplified were subjected to DNA sequencing to detect mutations. >Results: Out of 78 samples rpoB gene was amplified in 39 (50%), folP1 in 32 (41%) and gyrA in 45 (57.7%). In 20 (25.6%) samples no gene was amplified. Only 32 samples of rpoB, 25 samples of folP1 and 38 samples of gyrA gene were included in the study, rest were excluded due to sequencing error. No mutation was seen in rpoB gene and in folP1 gene. In gyrA gene samples mutations were seen in 8 (21%) samples, and were present at codon 91 GCA → GTA (Alanine → Valine). >Limitations: Small sample size and less efficient method to detect resistance. Conclusion: Resistance is not a problem with conventional drugs in MDT. It is more common with quinolones.

Summary Emphysematous pyelonephritis (EPN) is a rare necrotizing infection of renal parenchyma and/or urinary tract caused by gas producing organisms more commonly associated with diabetes mellitus. It has life threatening potential primarily due to septicemia and multiorgan failure and often requires nephrectomy. We report three patients with EPN who were managed with medical treatment and nephrostomy.

Background : Systemic therapy with methotrexate is a very useful modality in psoriasis, but relapses can occur soon after stopping it. Aim : To compare the relapse rates in psoriasis with two different tapering regimens of methotrexate after control is achieved. Methods : This was a randomized open-label controlled study, and patients of chronic plaque psoriasis with psoriasis area and severity index (PASI) >10 were included. Methotrexate 0.3 mg/kg weekly was given and the PASI calculated every 2 weeks. After achieving a 75% reduction in the PASI (PASI-75), patients were assigned randomly in to one of three groups. In the half-dose group, the dose of methotrexate was reduced to half and given weekly; in the 2-weekly group, the same dose was given at 2-week intervals; in the control group, methotrexate was stopped. Patients were followed up for 12 weeks. Results : Out of 141 registered patients, 81 were included: 27 in the half-dose group, 28 in the 2-weekly group, and 26 in the control group. After further exclusions due to adverse effects and loss to follow-up, the results were analysed for 16, 17 and 19 patients respectively in the 3 groups. There was statistically a highly significant difference in relapse rates between the half-dose and control groups (P < 0.001), and a significant difference between the 2-weekly and control groups (P = 0.001). Relapse rates in the half-dose and 2-weekly groups did not show a significant difference (P = 0.680). Limitation: Many (35.8%) patients were excluded and only 52 (64.2%) completed the study. Conclusion: There appears to be no significant difference in the frequency of relapse in psoriasis whether methotrexate is tapered by halving the weekly dose or by doubling the interval between two doses, and both methods led to fewer relapses than abrupt cessation of the drug.

Granuloma faciale (GF) is an uncommon, cutaneous disorder characterized by one to several soft, erythematous to livid papules, plaques, or nodules, usually occurring on the face. Extra-facial lesions occur rarely. We present a case report of 33-year-old male who presented with keloidal lesions on face and left shoulder. The patient didn't respond with intralesional triamcinolone and showed poor response with the addition of topical tacrolimus. Surgical excision in consultation with plastic surgeons is planned.

Granuloma annulare (GA) is a benign, inflammatory dermatosis involving dermis or subcutis with unknown etiology and poorly understood pathology. GA has characteristic histological features of necrobiosis, granuloma formation and abundant mucin deposition. Various predisposing factors, systemic diseases and drugs have been implicated in the etiology. We hereby describe a case of 70 year old male who was a known case of lepromatous leprosy, taking multidrug therapy for 6 months presented with multiple discrete, annular, firm, non tender, smooth surfaced skin colored papular lesions ranging in size from 0.5-1 cm over back for 1 month. There was past history of intake of allopurinol for hyperuricemia which was started 1 year back. There was history of similar lesions 6 months back which healed within 1 month of stopping allopurinol and he started taking the drug for the past 4 months on his own without any medical advice. Histopathological examination showed superficial and deep perivascular lymphocytic infiltrate with numerous histiocytes scattered in the intersititum of reticular dermis and abundant mucin in between the histiocytes. Allopurinol was implicated as an etiological agent and dramatic improvement was seen after stopping the drug for a period of 4 weeks. Naranjo's algorithm showed a probable association with a score of 6. Thus the final diagnosis of allopurinol induced generalised interstitial granuolma annulare was made. Patient was advised to continue antileprotic drugs, low purine diet and avoid allopurinol intake.

Incidence of pitting, vary considerably in different types of psoriasis. In clinical practice, toe nail examination is inconvenient. There are inadequate studies which show relation of nail pitting with duration and severity of the disease. The objective was to examine the incidence of finger nail pitting in all types of cutaneous psoriasis and its relation with different variables. This is a clinico-epidemiological study. A careful clinical examination of finger nails was done in day time. Severity of disease was calculated by psoriasis area severity index (PASI). Statistical analysis was done using Microcomputer statistics software (MSTAT). In study group, 621 patients and in control group 350 people were taken. Finger nail pitting was present in 37% (total number was < 20 in 17%; 20-60 in 8% and > 60 in 12%) in study group. In control group, it was present in 10% (in all cases total number was < 20). In < 1 year duration group, pitting was present in 32% of cases, while in > 1 year duration group it was 40.5%. In mild psoriasis, pitting was present in 34.2%, while in severe cases it was 47.6%. Finger nail pitting is an important nail finding in psoriasis and its incidence increases with duration and severity of disease.

A 55-year-old male presented with recurrent crops of crusted papular lesions and boils over buttocks for 1month along with a short history of productive cough. The diagnosis of papulonecrotictuberculid (PNT) with pulmonary tuberculosis was made based on history, clinical features, laboratory investigations, and response to antitubercular treatment.

Background: Prolonged and frequent use of topical steroids may lead to decrease in efficacy as well as many local adverse effects. Stratum corneum has a unique property of reservoir effect. Aims: To study the reservoir effect of topical steroids in a steroid-responsive condition which may enable a decrease in the dosing frequency of topical steroids. Methods: A cross-sectional study design was used. Patients with at least three vitiliginous patches of more than 2 cm 2 present over the trunk or limbs were included. Exclusion criteria were topical or systemic corticosteroid use within the previous 4 weeks, antihistamine use within the previous 7 days, history of any allergy in the past and immunosuppression. Clobetasol propionate cream was applied on the first vitiliginous area (site A) and fluticasone propionate ointment was applied on the second vitiliginous area (site B). The third vitiliginous area, site C (control site) was left without applying any medication. Histamine-induced wheal suppression test was performed on each site, at the same time of the day, on every consecutive day following steroid application, until the values obtained at sites A and B approached those obtained at site C. SPSS software for Windows, version 16.0 was used for statistical analysis. The mean and standard deviation of the various studied parameters were calculated for various treatment groups and compared using analysis of variance (ANOVA) test. Results: Forty patients were included in the study. The average wheal volumes and average erythema sizes at sites A and B were significantly smaller than the corresponding values at site C for up to 5 days after applying medication (P < 0.001). Limitations: The presence of a cutaneous reservoir of topical steroid was confirmed based on its suppressive effect on the wheal and flare response to histamine. It is not certain that the concentration that suppresses histamine-induced wheal and flare is sufficient for therapeutic efficacy in vitiligo. Conclusion: The reservoir effect of topical clobetasol propionate and fluticasone propionate persisted for 5 days in vitiliginous skin. Hence, it may be possible to reduce the frequency of topical steroid application in vitiligo.

Orofacial granulomatosis (OFG) is a rare disorder affecting the orofacial region, and clinically characterized by diffuse, nontender, soft to firm, painless swelling restricted to one or both lips and intraoral sites such as tongue, gingiva and buccal mucosa. Histologically, OFG is characterized by noncaseating granulomatous inflammation. The early diagnosis of OFG is essential for the better prognosis of the lesion. Delay in diagnosis of OFG results into formation of indurated and permanent swelling of the lip that not only compromises esthetic appearance but also causes impairment in function such as speaking and eating. Early diagnosis of OFG is challenging to the health care professionals due to clinical and histological resemblance to other chronic granulomatous disorders. Thus, dentists may act as a first person to diagnose the lesion and play an important role in the multidisciplinary treatment of granulomatous disorders. Here, we present a case of OFG affecting lips and gingiva in a 15-year-old patient without any identifiable systemic or local causes.

Though patients affected with both acquired immuno deficiency syndrome (AIDS) and leprosy commonly present with type 1 lepra reaction, there are few isolated reports of type 2 lepra reaction in retropositive patients affected with leprosy. We are presenting a case report of 35-year-old male affected with AIDS, tubercular lymphadenitis, and lepromatous leprosy with recurrent episodes of type 2 lepra reaction manifesting as erythema nodosum leprosum (ENL). Dipstick enzyme-linked immunosorbent assay (ELISA) for filarial antigen was also positive. The patient was treated with 100 mg thalidomide daily, 300 mg diethylcarbamazine, and modified multidrug therapy (MDT) for leprosy. He responded well and has not had any further reaction in the last 6 months.

Acroangiodermatitis or Pseudo-Kaposi sarcoma is a rare angioproliferative entity, related to chronic venous insufficiency or certain other vascular anomalies. It is often associated with chronic venous insufficiency, arteriovenous malformation of the legs, chronic renal failure treated with dialysis, paralyzed legs and amputation stumps. We hereby describe a case of 45 year old female presenting with pitting pedal edema, multiple ulcers over bilateral lower limbs with irregular margins with erythema and hyperpigmentation of the surrounding skin. Color Doppler study of bilateral lower limbs was normal. Histopathological examination from one of the lesions showed hyperplastic epidermis, proliferation of capillaries in dermis, hemosiderin deposits and lymphocytic infiltrate. These features thus confirmed the diagnosis of Acroangiodermatitis.

Connective tissue nevi of the skin are benign hamartomatous lesions consisting predominantly of one of the components of the extracellular matrix comprising of collagen, elastin or glycosaminoglycans type. Connective tissue nevi may be solitary or multiple, sporadic or inherited. Collagenomas are asymptomatic and usually occurs over upper trunk, arms, back, thighs and soles. We, hereby report a young boy with collagenoma over the scalp, a rare site.

“Tripe palms” or pachydermatoglyphy is a descriptive term of acanthosis nigricans of the palms and is associated with internal malignancy. It often precedes the diagnosis of a new or recurrent tumor. Malignant acanthosis nigricans is most commonly associated with intra-abdominal malignancies. In patients with both tripe palms and acanthosis nigricans, gastric carcinoma is the most common followed by lung carcinoma. There are very few reports in the literature of malignant acanthosis nigricans associated with gynecological malignancies. We report this case because of its rarity. A 47-year-old lady presented with lower abdominal swelling and progressive hyperpigmentation which preceded the abdominal swelling by 6 months. On investigations, she was found to have ovarian cancer. The presence of acanthosis nigricans in conjunction with tripe palms in a female patient is highly suggestive of an internal malignancy including an ovarian cancer and demands an extensive search for the hidden ovarian cancer.