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   Table of Contents - Current issue
Coverpage
July-September 2021
Volume 22 | Issue 3
Page Nos. 195-291

Online since Wednesday, June 30, 2021

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REVIEW ARTICLE  

Topical therapy for atopic dermatitis: A review Highly accessed article p. 195
Khushboo Minni, Robert Sidbury
DOI:10.4103/ijpd.ijpd_148_20  
Background: Pediatric atopic dermatitis(AD) is very common, but its management is frustrating for the dermatologist, child and parents alike as this chronic inflammatory skin disease is marked with numerous difficult to control flares. Although country specific guidelines for AD exist, there is paucity of data with respect to dedicated topical care regimens for AD management in pediatric population. Purpose: This is a broad based review exploring various topical practices and management options to manage pediatric AD during flares and in remissions. Scope: The PubMed database was searched (to 1 June 2020) for English-language articles containing the keywords atopic dermatitis, atopic eczema, topical calcineurin inhibitor(TCI), topical corticosteroid(TCS), topical phosphodiesterase inhibitors, crisaborole, topical therapy. Articles focusing on topical managment for children with AD were chosen for further review. A limitation is that this is not a systematic review of the literature. We have relied heavily on The Indian Dermatology Expert Board Members 2019 Management Guidelines on AD and the 2014 American Academy of Dermatology (AAD) guidelines, soon to be updated. In our review, we focus on Skin directed therapies to repair and maintain healthy skin barrier, suppress inflammatory response, control flares, control itch and manage infectious triggers. Topicals can be used as first line therapy in mild AD, adjuvant for moderate-severe AD or as maintenance to keep the disease in remission. Topical therapy in AD is not limited to TCS, TCI, Crisaborole or newer molecules but also involves moisturization, emollient care and bathing practices; which have been discussed. Conclusion: Multiple topical therapies and practices have been successfully used to treat children with AD. An understanding of the available treatment options will help dermatologists striving to achieve best practice in the management of pediatric AD.
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ORIGINAL ARTICLES Top

Pediatric dermatophytosis of the skin: current clinico epidemiological and antifungal susceptibility patterns in a tertiary care rural hospital p. 215
Pranami Kashyap, Yadalla Kumar Kishan, R Prakash
DOI:10.4103/ijpd.IJPD_92_20  
Background: Dermatophytosis is a common infection seen in tropical countries like India. With the onset of the 21st century, cases of antifungal resistance in dermatophytoses began to emerge as a therapeutic challenge. While tinea capitis, the predominant presentation in pediatric age group, has been extensively studied, the current scientific literature lacks in articles that assess the antifungal susceptibility patterns in pediatric dermatophytosis particularly involving the skin. Objective: This study attempts to identify and assess the changing clinico-epidemiological trends in the profile of pediatric dermatophytosis involving the skin, and its antifungal susceptibility patterns. Materials and Methods: Thirty subjects of 0–18 years of age with clinically diagnosed dermatophytosis were evaluated with history, examination and followed by a potassium hydroxide wet mount. Skin scrapings were also taken for fungal culture and antifungal susceptibility test against 10 commonly used antifungal agents using Broth Microdilution method as per Clinical and Laboratory Standards Institute (CLSI) M38-A2 guidelines. Results: Trichophyton rubrum was the most common dermatophyte isolated. Recurrent dermatophytosis was seen in 20% subjects. Tinea corporis was the predominant presentation. Steroid-modified Tinea was observed in 33.33% cases. Based on in vitro antifungal susceptibility testing, terbinafine and luliconazole were found to be the most effective systemic and topical agents, respectively. Conclusion: The rampant use of over-the-counter medications containing topical steroids is a rising issue in the treatment of both adult and pediatric dermatophytosis. Education and counseling of patients are very important for correct treatment of the condition and also to prevent the rise of recurrent infections.
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Assessment of impact on quality of life in children attending skin outpatient department with pediculosis capitis: A study in Western Rajasthan p. 220
Anand Kumar, Alpana Mohta, Aditi Agrawal, Atul Mohta
DOI:10.4103/ijpd.IJPD_70_20  
Background: Pediculosis capitis is an endemic infestation prevalent worldwide and common among primary school girls with low socioeconomic background. Aims and Objectives: The objective of this study is to determine the various risk factors associated with pediculosis, Children's Dermatology Life Quality Index (CDLQI), and its correlation with the various risk factors. Materials and Methods: Sixty-one children of age group of 6–12 years who were clinically diagnosed with pediculosis capitis at our outpatient clinic were included in this study. Demographic details and risk factors along with CDLQI were obtained from the patients on a preformed written pro forma. Statistical Analysis: It was performed on the SPSS software version 22 using the Mann–Whitney U and ANOVA test; P < 0.05 was considered statistically significant. Results: Of 61 patients, all were female with a moderate impact on quality-of-life children. Mean CDLQI was 9.8 ± 6.04 and most common affected domain was of symptoms and feelings with a mean of 3.53 ± 1.45. Other domains affected were sleep and treatment-seeking difficulties with a mean of 1.69 ± 1.03 and 1.64 ± 0.81, respectively. Girls of the rural community with longer hairs, poor hygiene, and lower socioeconomic class, i.e., class 5 had a higher impact on their lives as compared to others with a mean CDLQI of 14.83 ± 6.08, 10.36 ± 5.43, 15.06 ± 6.51, and 13.42 ± 6.74, respectively. Conclusion: Community-based health programs and delousing campaigns are needed to create the awareness among people so that good hygiene practices can act as a primary preventive measure against pediculosis capitis and prevent any deleterious impact on the lives of children.
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A cross sectional study of nutritional dermatoses among malnourished children in a tertiary care centre p. 226
Vishalakshi S Pandit, K Udaya
DOI:10.4103/ijpd.IJPD_13_20  
Background: Nutritional deficiencies are most prevalent in underdeveloped and developing countries of the world. An impaired nutritional status alters the structural integrity and biological function of the skin, resulting in an abnormal skin barrier. The objective was to study the various cutaneous spectrums of nutritional deficiency (ND) in children. Methods: A total of 100 malnourished children were included over a period of 6 months. Preliminary data of children regarding age, start of complementary feeding, maternal education, and parity were recorded. All children were examined thoroughly for the presence of cutaneous, mucosal, hair, and nail changes. Results: Majority were in the age group of 6–24 months, followed by 25–36 months. M:F ratio was 1:1.1. Majority of mothers were illiterate (43%). Only 8% babies were bottle-fed and complementary feeding was started in 56% of children between the months of 6 and 12. Seventy percent children were born to multiparous mothers. Approximately 50% children were of low-birth weight. Ninety-four percent of families resided in the rural areas. The cutaneous features seen include xerodermia (58%), lusterless hair (53%), pigmentary changes (36%), loss of subcutaneous fat (31%), flag sign (29%), angular cheilities (20%), etc. Other features seen were monkey-like facies (4%), long eyelashes (16%), ichthyotic and lichenoid skin changes (16%), and flaky paint dermatosis (2%). Conclusions: The most common cutaneous feature seen was xerodermia and least frequent one was flaky paint dermatosis. Many cases of ND are diagnosed only after evident skin changes. There is significant morbidity and sometimes mortality associated with certain nutritional deficiencies. Their prompt recognition, diagnosis, and treatment by clinicians are of great importance.
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Mucocutaneous manifestations in dengue: A study among children at a tertiary care center in South India p. 231
Jogin Veeresh, Sambasiviah Chidambara Murthy, Banavasi Vishwanath
DOI:10.4103/ijpd.IJPD_37_20  
Introduction: Dengue, a viral illness, is a major public health problem. Mucocutaneous manifestations are known to occur in this illness. Over the past three decades, there has been a dramatic global increase in the incidence of dengue fever (DF). Our objective was to study the frequency and pattern of mucocutaneous manifestations of DF in children. Methodology: A total of 210 consecutive cases, which were serologically confirmed and admitted to pediatric ward over a period of 12 months (January to December 2018), were included. A detailed clinical history, examination and relevant investigations were carried out. Data were entered into a pro forma and analyzed using simple statistical methods and Chi-square test (wherever applicable). Results: The most common age group affected was 4.1–8 years with a mean age of 6.3 ± 3.9 years. Male children were more commonly affected, with majority from urban areas. Maximum cases were noted during the months from October to December, i.e., winter season. Mucocutaneous findings were noted in 112 (53.3%) cases. Cutaneous rash was present in 43 (20.1%) cases. The most common site involved was trunk, followed by face and others. Macular erythema was the most common type of rash. Onset of rash was more commonly seen in children with depleted platelet count. Ocular and oral mucosae were involved in 56 (26.7%) and 42 (20.1%) cases, respectively. Conclusion: Mucocutaneous manifestations are relatively common in children with dengue. Cutaneous rash may be a useful clinical clue for early diagnosis of dengue. Awareness of mucocutaneous manifestations helps in early recognition and proper management of dengue.
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A cross sectional observational study of pediatric dermatophytosis: Changing clinico mycological patterns in Western India p. 236
Shital Poojary, Saurabh Jaiswal, Krishna B Bhalala, Jimish Bagadia, Kapisha S Shah, Suby Arora, Yesha Ruchir Patel, Pawan Gupta, Khanda S Khot, Ashish Rai, Mamta Dhayal
DOI:10.4103/ijpd.IJPD_63_20  
Introduction: The last few years have seen a significant rise in the incidence of dermatophytosis across India. Vulnerability of children to this disease is more than adults due to multiple factors. However, limited data are available regarding clinical and mycological variants of dermatophytosis in children. Materials and Methods: A cross-sectional observational study was designed at the dermatology outpatient department in Mumbai. The aim of the study was to assess the clinical profile and identify the causative fungal species in pediatric dermatophytosis. Sixty-seven children below 14 years of age with a clinical diagnosis of dermatophytosis were included by the simple random sampling method. A detailed history (duration of lesions, topical creams used, similar lesions in contacts, contact with pets, and other comorbidities/comedications) was taken and clinical examination (sites of involvement, number of lesions, associated erythema/scaling, morphology, and extent of lesions) was done followed by fungal mount preparation (potassium hydroxide (KOH) and KOH with Chicago Sky Blue stain) and culture of the scrapings on Sabouraud's agar medium containing chloramphenicol and cycloheximide. Microsoft Excel and SPSS-20 software were used to analyze the data. Results: A total of 42 male and 25 female children (mean age – 6.2 years) were included in the study. Prior topical applications of steroids±antifungal combinations were used in 57 cases (85%) before presenting to the dermatologist. About 76.12% (n = 51) of cases had positive family/contact history. Thirty-five children (52.2 %) had extensive disease. Multiple atypical clinical patterns were observed: tinea incognito, irregular geographic plaque, tinea recidivans, tinea pseudo-imbricata, penile tinea, and annular plaques on scalp. Trichophyton mentagrophytes complex was the most common isolate from cultures grown from scrapings, in 14/19 cases (73.7%). Conclusion: This clinico-mycological study highlights the changing clinical patterns (including Tinea pseudoimbricata, geographically patterned plaques) and shift in the etiological agent in childhood dermatophytosis. The study brings into focus the increasing proportion of T. mentagrophytes, high percentages of topical steroid abuse by parents in children, and positive family/close-contact history in children.
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CASE REPORTS Top

An unusual presentation of cutaneous Rosai Dorfman Disease in a child p. 241
Seujee Das, Pankaj Adhicari, Bornali Dutta, Ekta Jajodia
DOI:10.4103/ijpd.IJPD_78_20  
Introduction: Rosai-dorfman disease (RDD) is a self-limiting, non-Langerhans cell histiocytosis of unknown etiology. It was originally thought to involve only the lymph nodes, however recent literature suggests extranodal involvement as wel. Case Report: Herein we report a case of cutaneous RDD in a six year-old girl, presenting with multiple subcutaneous nodules. Discussion: Cutaneous RDD is an extremely rare entity and unlike classic RDD, it has a predilection for the age group above 40 years and is more common in females. It is extremely rare in children.
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Raynaud's phenomenon in an adolescent girl: A case report p. 244
Rajkumar Motiram Meshram, Vishal S Gajimwar, Siddhant Gholap, Madhuri Jhanwar
DOI:10.4103/ijpd.IJPD_31_20  
Introduction: Triphasic color change of the distal extremities in response to cold and emotional stress is known as Raynaud's phenomenon (RP). Fingers, toes, nose, and ears are the commonly affected organs. Secondary RP is usually associated with underlying connective tissue disorder. Case Report: An 11-year-old adolescent girl presented with bluish discoloration of digits and toes, which were more marked on cold exposure. She had a positive antinuclear antibody test. Her grandmother was a known case of rheumatoid arthritis. She was managed with nifedipine, counseling and avoidance of cold environment. Discussion: It is essential to search for any underlying causes especially connective tissue diseases in such cases. Effective education and clear explanation about the disease reduce the anxiety and improve the quality of life.
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Bullous systemic lupus erythematosus as a presenting manifestation of systemic lupus erythematosus in a child p. 247
Sumedha Ballal, Mary Augustine, Rajalakshmi Tirumalae
DOI:10.4103/ijpd.IJPD_101_20  
Introduction: Bullous systemic lupus erythematosus (BSLE) is a rare blistering disorder seen in the background of systemic lupus erythematosus (SLE). It can either be a presenting feature or manifest later in an established case of SLE often accompanied by lupus nephritis. Case Report: We report a case of a 12-year-old girl in whom the presenting feature of SLE was BSLE, along with hemolytic anemia. Discussion: Bullous SLE should be considered in the differential diagnosis in children presenting with vesiculobullous lesions even in the absence of established SLE
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Eosinophilic annular erythema in childhood: A distinct entity p. 250
Chetan D Rajput, Balkrishna P Nikam, Neeta K Hatkar
DOI:10.4103/ijpd.IJPD_98_20  
Introduction: Many conditions included under figurate erythemas have similar clinical appearance which makes diagnosis difficult. Among these, eosinophilic annular erythema (EAE) is a rare, uncommon, underreported entity in the pediatric population. Case Report: Herein, we report an 11-year-old boy who presented with asymptomatic recurrent, erythematous-edematous annular plaques with central hyperpigmentation. Discussion: Review of the literature shows scarce reporting of such cases globally and none from India. Clinicopathological findings of our case, suggest that eosinophilic annular erythema is a distinct entity rather than a type of Wells' syndrome.
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Acquired cutis laxa secondary to sweet syndrome (marshall syndrome) in a 2-year-old child p. 254
Gowrappala Shanmukhappa Asha, Seetharampura Ramamurthy Radhika, Kanathur Shilpa, Heera Ramesh
DOI:10.4103/ijpd.IJPD_89_20  
Sweet syndrome (SS) is a neutrophilic dermatosis which is rarely seen in early childhood. Usually, in children, the SS is predominantly of classic/idiopathic type. In 40%–45% of cases, it is secondary to infections. Acquired cutis laxa (ACL) Type II also known as Marshall syndrome is also a very rare cutaneous condition seen in children. Only ten cases have been reported till now. We report this case of a 2-year-old girl with recurrent SS and ACL Type II, who was treated initially with tapering doses of steroids and saturated solution of potassium iodide for maintenance.
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Phenomenal role of nitroglycerin in the treatment of neonatal digital gangrene p. 257
Rahul Choudhary, Susil Choudhary, Garima Sachdeva, Arti Maria
DOI:10.4103/ijpd.IJPD_117_20  
Introduction: Placement of peripheral venous catheter is a common requirement for the neonates requiring intensive care unit admissions. This simple procedure can sometimes lead to catastrophic complications such as peripheral tissue ischemia/gangrene. This is particularly common in preterm neonates. Effective treatment is very important to prevent long-term sequelae or need for amputation. Nitroglycerin (NTG) is a potent smooth muscle relaxant and improves vascular flow. Case Report: Here, we report a case of neonatal digital gangrene which was successfully treated with topical NTG with no adverse outcome. Discussion: Topical NTG is a potential treatment option for neonatal peripheral gangrene.
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Congenital insensitivity to pain with anhidrosis and compensatory hyperhidrosis p. 260
Aradhana Rout, Sandeep Arora, Shamsher Singh Dalal, Sudeep Kumar
DOI:10.4103/ijpd.IJPD_107_20  
Hereditary sensory and autonomic neuropathy is a rare syndrome characterized by congenital insensitivity to pain, temperature changes, and an autonomic nerve formation disorder. We report an 8-year-old boy who presented with late-onset of self-mutilating behavior, insensitivity to pain, temperature, and anhidrosis with compensatory hyperhidrosis. Exome sequencing revealed a mutation of the SCN9A gene at chromosome 2 with nucleotide change c. G554A/p. Arg185His at exon 5 along with HSPB1 mutation at chromosome 5.
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Dowling Degos Disease in a child: A rare case report from Northeast India p. 264
Romita Bachaspatimayum, Nandita Bhattacharjee, Priyanka Das
DOI:10.4103/ijpd.IJPD_12_19  
Dowling–Degos disease (DDD) is a rare genodermatosis with autosomal dominant inheritance. It is characterized by reticulate pigmentation of flexures, comedo-like follicular papules, and perioral pitted scars. Here, we report a 3-year-old female child presenting with hyperpigmentation of the external genitalia, intergluteal fold, and armpits with follicular keratotic papules over the neck. Histopathological examination showed hyperkeratosis, irregular acanthosis, papillomatosis, and basal layer pigmentation in the epidermis with elongated and branched rete pegs and relatively more melanin concentration in the tips of the rete pegs. The diagnosis of DDD was made. This case is reported due to the unusual early onset and involvement of external genitalia.
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A heterozygous missense mutation of CARD14 gene in a case of Netherton-Like syndrome p. 267
Surya Ravindran, Sebastian Criton, Divya Surendran
DOI:10.4103/ijpd.IJPD_72_20  
Netherton syndrome (NS) is a multi-domain genodermatoses with hair, skin, and immunological abnormalities caused by a monogenic serine protease inhibitor of Kazal type 5 mutation. As it presents with a myriad of overlapping clinical features, it often creates a diagnostic confusion from other congenital erythroderma causes. The molecular basis of NS was investigated in a 7-month-old male child using next-generation sequencing. Sequencing identified an A-to-G transition at producing the missense mutation p.Met238Val in exon 5 of the CARD14 gene. This study suggests the occurrence of the CARD14 gene as a novel missense mutation in NS and suggests that it may be a recurrent abnormality and the probable reason for the atypical features of this genodermatosis presenting as congenital erythroderma.
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Oral mucosal Myiasis: A rare association with pediatric SJS-TEN overlap p. 271
Annie Raizada, Tushita Ghosh, Maitreyee Panda, Anuspandana Mahapatra
DOI:10.4103/ijpd.IJPD_28_20  
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) overlap is a severe cutaneous adverse reaction with predominantly drug-related etiology which is an immune complex mediated hypersensitivity disorder. Oral myiasis is defined as an intra-oral infestation of the living tissues of animals or humans by dipteral larvae. Herein, we report a rare case of an eight-year-old female child who presented to us with SJS-TEN overlap and was accidentally diagnosed with oral myiasis during her course of hospitalisation. This case report gives an overview of oral mucosal myiasis in childhood as a rare association with SJS-TEN overlap.
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RESIDENT CORNER Top

Café-au-lait Macules p. 274
Sushrut Save, Resham Vasani
DOI:10.4103/ijpd.ijpd_62_21  
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LETTERS TO EDITOR Top

Epidermal nevus syndrome with rare ocular and skeletal features p. 280
Neerja Puri, Sukhmani Brar, Jatinder Pal Singh
DOI:10.4103/ijpd.IJPD_93_20  
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Late onset Vitamin K deficiency bleeding disorder presenting as nodular purpura in a 3-month-old exclusively breastfed infant p. 282
Sakshee Madan, Shikhar Ganjoo, Richa , Shashi Sharma
DOI:10.4103/ijpd.IJPD_124_20  
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Aloe Vera treatment for acne resulting in allergic contact dermatitis p. 284
Ghanshyam Kumar Verma, Gita Ram Tegta, Ajeet Kumar Negi, Amit Chauhan
DOI:10.4103/ijpd.IJPD_21_19  
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Changing hair color p. 286
Rachna Sehgal, Ratan Gupta, Meenakshi Bhatt
DOI:10.4103/ijpd.IJPD_96_20  
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Factitious disorder imposed on another: A report of two cases p. 288
Ramesh Kumar Kushwaha, Alpana Mohta, Pritee Sharma, Suresh Kumar Jain
DOI:10.4103/ijpd.IJPD_59_20  
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OBITUARY Top

In memory of Prof. Ashok Kumar Bajaj (December 24, 1945–January 22, 2021) p. 290
Deepak Parikh, PK Srivastava, Sandipan Dhar
DOI:10.4103/ijpd.ijpd_68_21  
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