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Byline: Durairaj. Arjunan, Liza. Das, Sanjay. Bhadada, Manjul. Tripathi, Tarun. Narang, Pinaki. Dutta Sir, Cutis vertices gyrata (CVG) is a rare cutaneous manifestation characterised by deep furrows and convoluted folds [...]

Leprosy remains a significant public health concern despite major strides in treatment and control efforts. The Global Leprosy Strategy 2021–2030 and the National Strategic Plan for Leprosy 2023–2027 majorly focus on facilitating action to reach the goal of zero leprosy. Exploration of new treatment regimens is emphasized as one of the verticals of the multipronged approach for reaching the aforementioned goals. This becomes particularly pertinent in the wake of growing evidence for resistance to the drugs currently being used in the management of leprosy. Repurposed molecules present a very good approach in this direction. The present review aims to explore the potential of bedaquiline, a drug used for multidrug‐resistant tuberculosis, as a potential addition to the therapeutic armamentarium of leprosy. Through this narrative review, the authors attempt to look into the available proof of concept, clinical evidence, potential risks, and possible ways forward with bedaquiline in leprosy. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Leprosy is known to be a great mimicker. Its dermatoscopic evaluation may be of value in establishing diag- nosis. Objective: To study the dermatoscopic findings encountered across the leprosy spectrum. Methods: This was a multi-centre cross-sectional study of leprosy patients, where after a thorough cutaneous and neurologi- cal evaluation, representative skin lesions from the study patients were photographed in standard settings, and the most repre- sentative skin lesions were chosen for dermatoscopic evaluation. Data was entered in a structured proforma and a descriptive analysis of dermatoscopic patterns was carried out. Results: A total of 53 cases of ages between 14 and 80 years, ranging from tuberculoid to the lepromatous spectrum of dis- ease, with active skin lesions in the form of patches and plaques were included. The spectrum of leprosy as per Ridley-Jopling classification at diagnosis was indeterminate in 1 (1.9%), tuberculoid in 1 (1.9%), borderline tuberculoid in 25 (21.5%), bor- derline lepromatous in 9 (17%), lepromatous in 14 (26.4%) and histoid in 3 (5.7%). Dermatoscopic features included distort- ed pigment network in 48 (90.6%), focal white areas in 40 (75.5%), reduced eccrine and follicular openings in 43 (81.1%), widened skin lines in 28 (52.8%), circle hairs in 15 (28.3%) and white shiny streaks in 17 (32.1%). Conclusion: Dermatoscopy is a practical, non-invasive device to assess skin lesions of leprosy and provide cues to its diag- nosis, spectral classification and differentiating it from other granulomatous disorders. However, dermatoscopy alone cannot reliably differentiate between the various types of leprosy and future large-scale studies are required. Limitations of the study: The numbers for each subtype were variable and few in some spectrum of leprosy patients. A dermatoscopic-histologic correlation was not done. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion There is a limited number of studies assessing the alterations in nerve function impairment (NFI) in leprosy over an extended period of time. To the best of our knowledge, no published study has evaluated neurological state longitudinally during treatment utilizing a combination of clinical, functional (activity limitation), electrophysiological, and patient‐reported quality of life (QOL) outcomes.This prospective, observational study included leprosy patients of all spectra. Over 1 year of treatment, cutaneous and neurological examinations were done in addition to a nerve conduction study (NCS) and sympathetic skin response (SSR) assessment. QOL and activity limitation assessments using the World Health Organization Quality of Life brief version (WHOQOL–BREF) and Screening of Activity Limitation and Safety Awareness scale (SALSA), respectively, were also performed.Out of 63 leprosy patients, loss of sensation was noted in 43 (68.2%) at baseline. At the completion of treatment, proportionate change revealed no change in 18 (28.5%), restored function in 9 (14.2%), improved status in 34 (53.9%), and deteriorated NFI in only 2 (3.1%) cases. The association between NCS‐SSR abnormalities was significant for a longer duration of disease at presentation (P = 0.04), in multibacillary cases [OR 9.12 (95% CI, 1.22–67.93)], in those in reaction [OR 3.56 (95% CI, 0.62–20.36)] and in those aged over 40 [OR 1.93 (95% CI, 0.28–13.41)]. There was an improvement in WHOQOL‐BREF and SALSA scores at release from treatment (P = 0.005 and P = 0.01, respectively).The majority of leprosy patients on treatment show improvement in NFI at the completion of therapy. However, change is influenced by critical factors such as bacillary load, disease duration, age, and the presence of reaction(s). [ABSTRACT FROM AUTHOR]

Background This study aimed to assess the effectiveness of nurse-led interventions in managing leprosy due to a shortage of dermatologists and other healthcare professionals. Methods A total of 100 leprosy patients were divided into experimental (n=50) and control groups (n=50). The intervention included face-to-face counseling by a trained nurse, motivational videos and exercise demonstrations. The control group received standard care. The primary outcome of interest was treatment adherence (Adherence to Refills and Medications Scale); other assessed outcomes included changes in perceived stigma (Stigma Assessment and Reduction of Impact scale), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder seven-item) and quality of life (WHO QOL–BREF Scale) from baseline to week 8. Results The intervention group had better treatment adherence (p<0.001). At baseline, moderately severe and severe depression prevalence was 18% and 28%, respectively, and anxiety was 25%, with no intergroup differences. Anxiety significantly decreased in the intervention group (p<0.001), but depression remained similar (p=0.291). Perceived stigma improved notably, especially in disclosure of concern (p<0.001), internal stigma (p<0.001) and anticipated stigma (p<0.001). Quality of life scores improved in the intervention group vs controls. Conclusion Nurse-led interventions effectively enhanced quality of life and treatment adherence and reduced anxiety, depression and perceived stigma among leprosy patients. The study recommends strengthening the capacity of nurses for active involvement in leprosy care. [ABSTRACT FROM AUTHOR]

Background: Palmoplantar psoriasis (PPP), a troublesome variant, does not have any validated scoring system to assess disease severity. Objective: To validate modified Palmoplantar Psoriasis Area and Severity Index (m-PPPASI) in patients affected with PPP and to categorise it based on Dermatology Life Quality Index (DLQI). Methods: In this prospective study, patients with PPP aged > 18 years visiting the psoriasis clinic at a tertiary care centre were included and requested to complete DLQI during each visit at baseline, 2nd week, 6th and 12th week. m-PPPASI was used by the raters to determine the disease severity. Results: Overall, 73 patients were included. m-PPPASI demonstrated high internal consistency (α = 0.99), test-retest reliability of all three raters, that is, Adithya Nagendran (AN) (r = 0.99, p < 0.0001), Tarun Narang (TN) (r = 1.0, p < 0.0001) and Sunil Dogra (SD) (r = 1.0, p < 0.0001) and inter-rater agreement (intra-class correlation coefficient = 0.83). Face and content validity index for items I-CVI = 0.845 were robust, and the instrument was uniformly rated as easy to use (Likert scale 2) by all three raters. It was found to be responsive to change (r = 0.92, p < 0.0001). Minimal clinically important differences (MCID)-1 and MCID-2 calculated by receiver operating characteristic curve using DLQI as anchor were 2 and 35%, respectively. DLQI equivalent cutoff points for m-PPPASI were 0–5 for mild, 6–9 for moderate, 10–19 for severe, and 20–72 for very severe disease. Limitations: Small sample size and single-center validation were the major limitations. m-PPPASI doesn’t objectively measure all characteristics of PPP such as “fissuring” and “scaling” which could also be taken into consideration. Conclusion: m-PPPASI is validated in PPP and can be readily utilized by physicians. However, further large-scale studies are needed. [ABSTRACT FROM AUTHOR]

Primary cutaneous plasmacytosis (PCP) is an uncommon reactive lymphoplasmacytic disorder of uncertain etiology. It has been mainly described in patients of Japanese descent, with only few reports in Caucasians and Chinese. We present a case of isolated benign PCP in a 45-year-old man, who clinically manifested with a localized ulcerated nodule overlying a hyperpigmented plaque on the upper back. To the best of our knowledge, PCP from India has not been described before.

A study was conducted in a peri-urban community near Chandigarh, India, to assess the prevalence of skin disorders. The study found that fungal infections were the most common diagnosed skin disease, followed by psoriasis, urticaria, atopic dermatitis, and vitiligo. Allergies and itching were the most common self-reported skin complaints. The study also revealed that a significant number of participants were not seeking medical treatment for their skin problems. The findings suggest a need for increased access to dermatological care in rural and peri-urban areas. [Extracted from the article]

Methemoglobinemia (MetHb) is an uncommon and fatal condition. It is usually suspected when there is a discrepancy between the pulse oximetry reading and arterial blood gas analysis findings. Treatment depends on the level of MetHb and symptoms. Here, we present a case of an elderly male with lepromatous leprosy on regular therapy who developed influenza infection leading to the precipitation of erythema nodosum leprosum (ENL) and hypoxia due to drug-induced MetHb. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Fixed duration multidrug therapy (FDT–12 months) is recommended by the WHO for multibacillary (MB) Hansen's disease (HD). However, highly bacillated patients tend to experience problems such as painful neuritis, worsening nerve function, delayed regression of lesions, and relapses. There is also concern about the increasing rate of relapse and antimicrobial resistance. Persistent or slowly regressing skin lesions and disabilities can occur even after completion of treatment. The decline in expertise to diagnose and treat Hansen's disease and poor treatment adherence are additional challenges. It is suggested that prolonging antimicrobial therapy, adding immunotherapy, increasing the dosage of rifampicin, adding more potent bactericidal drugs, and improving diagnostic services and treatment adherence may help manage highly bacillated patients. [Extracted from the article]

Background: The nationwide lockdown imposed due to the COVID-19 pandemic disrupted daily routines, especially for children. Being at home and attending virtual classes unintentionally precipitated an increase in both academic and nonacademic screen time and probably led to decreased physical activity in children. However, there is lack of evidence related to the physical activity and screen time of school-age children during the COVID-19 pandemic. So this study aimed to investigate the effect of the COVID-19 pandemic and lockdown on physical activity and screen time of children. Methods: An online survey was used to recruit parents of school-age children through convenience sampling. Parents were asked to compare their child's physical activity and screen time in the previous week with those in the pre-lockdown and lockdown periods. The global physical activity questionnaire was used to assess physical activity, and a screen time questionnaire was developed and validated. Data collection was done from September 2020 to December 2020. Results: Data of 104 children were collected from parents' reports. The average age of parents was 39.1 + 4.8 years for mothers and 40.8 + 6.9 years for fathers. Results revealed a decrease in physical activity from 564.95 min/week before the lockdown to 146.05 min/week during the lockdown, with the absolute decrease of 448.9 min/week. Total screen time increased from 2.42 h/day before the lockdown to 7.41 h/day during the lockdown. Conclusion: Necessary steps to mitigate the effect of COVID-19 pandemic unintentionally affected children in terms of decreased physical activity and increased screen time. [ABSTRACT FROM AUTHOR]

Mycobacterium indicus pranii (MIP), previously called Mw vaccine, is a one-of-a-kind immunomodulatory vaccine. It was indigenously developed in India for use in leprosy. MIP is heat-killed Mycobacterium w, which is a non-pathogenic atypical mycobacterium belonging to Class IV of Runyon classification. It shares epitopes with Mycobacterium leprae and Mycobacterium tuberculosis, which forms the rationale behind its use in leprosy and tuberculosis. MIP activates both innate and acquired immunity. It induces a Th1 and Th17 immune response along with downregulation of Th2 pathway and activates macrophages and dendritic cells. MIP vaccine is safe with adverse effects such as local site erythema, swelling, and rarely fever and other systemic reactions. Apart from leprosy, MIP has been used in dermatological diseases such as warts and psoriasis. Clinical trials have evaluated the efficacy of MIP in a plenitude of non-dermatological conditions such as category II tuberculosis, Gram-negative sepsis, non-small cell lung cancer, human immunodeficiency virus (HIV), muscle-invasive bladder cancer, and very recently, coronavirus 2019 (COVID-19). In vitro and animal studies have also demonstrated its utility in leishmaniasis, melanoma, and as a vaccine for the prevention of pregnancy. The PubMed database was searched using "Mycobacterium indicus pranii, MIP, Mycobacterium w" as the keyword in title. This comprehensive review provides useful information for healthcare professionals about immunotherapeutic potential of MIP vaccine, its composition, dosing schedule, administration, and side effects besides its efficacy in various indications other than leprosy. [ABSTRACT FROM AUTHOR]