Nepal Journal of Dermatology, Venereology & Leprology

Topical Corticosteroids Misuse: A Burning Issue

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23116

Since the introduction of hydrocortisone into dermatology, a tremendous development has occurred in the field of topical corticosteroids. With the growing use of topical corticosteroids, a serious concern for its misuse is to be highlighted. This matter is of a great concern. Proper guidelines and legislation on the use of topical corticosteroids are warranted to combat this serious issue.

Keywords: Glucocorticoids, Hydrocortisone, Nepal, Nonprescription drugs

Upcoming Therapeutic Modalities for the Treatment of Keloids: An Update

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23333

Introduction: Keloids are benign dermal tumors that generally form by local fibroblast proliferation and excessive collagen production following skin trauma. Several methods have been described for the treatment of keloid, often with suboptimal results and recurrences.

Objective: To update literature that provides information regarding upcoming therapeutic modalities for the treatment of keloids, including lasers, radiofrequency (RF), photodynamic therapy (PDT), and ultraviolet A1 (UVA1) irradiation.

Materials and Methods : A systematic review of the literature was performed for the original articles related to the treatment of keloids. The search terms ‘keloids’ and ‘lasers’ or ‘radiofrequency’ or ‘PDT’ or ‘UVA1’ was entered into a search of the National Library of Medicine’s PubMed Database.

Result: The search returned a total of 188 sources, of which, 26 articles met our inclusion criteria.

Conclusion: Combination approach is superior than solo therapy in the treatment of keloid. However, it is highly desirable that new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for the treatment of keloid. Moreover, lack of randomized clinical trials (RCTs) needs to be taken into consideration urgently.

Keywords: Collagen, Fibroblasts, Keloid, Photochemotherapy, Ultraviolet therapy

Patch Testing In Nepalese Population: A Single Center Study From Kathmandu, Nepal

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23118

Introduction: Patch testing is a diagnostic tool used in investigation to identify specific allergens in allergic contact dermatitis (ACD). It helps find the prevalence and the trends of contact sensitization in the community.

Objective: To report the two year patch test results from a central hospital in Kathmandu.

Materials and Methods: Consecutive consenting patients of suspected ACD were patch tested with an Indian standard Series (Systopic) from June 2014 to August 2016.

Results: Out of 141 patients tested, 89 were female (63.12%) and 52 were male (36.88%). Hand eczema was the commonest pattern (53 patients) followed by persistent and recurrent eczema (44 patients) and face eczema (25 patients). Fifty- five patients (39%) had at least 1 positive allergic reaction. Among these, 16.31% were male and 22.70% were female. The most common allergen was nickel sulfate (19.9%) followed by fragrance mix (7.8%) and paraphenyldiamine (PPD) (6.4%). Out of total positive cases 27 (21 females and 6 males) had shown strong positive reactions (++). The Nickel Sulfate was responsible in majority of cases (18/27 cases). Farmers had the highest (57.14%) rate of positive allergic reactions followed by housewives (39.62%). According to the regional eczema, patients with persistent and recurrent eczema of different parts of body had the highest rate of positive allergic reactions (47.72%). Almost half of patient with facial eczema (40%) had positive patch test.

Conclusion: Larger studies are required in the different parts of the country to find a more accurate data regarding the sensitization pattern in Nepalese population.

Keywords: Allergens, Dermatitis, Allergic Contact, Eczema, Nickel sulfate

Association between Serum Zinc Level and Cutaneous Viral Warts: A Case Control Study

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23153

Introduction: Cutaneous viral warts are one of the common skin disorders in general population which can affect any age group and any gender in any country and pose a significant health problem. A possible association with zinc has been suggested in previous studies. Zinc is known to be required for efficient functioning of immune system.

Objective: To find out the association between serum zinc level and cutaneous viral warts.

Materials and methods: In this case-control study, total of hundred patients were enrolled. Among them 50 (males – 27, females – 23) with cutaneous viral warts were taken as cases and 50 (males – 25, females – 25) healthy individuals were taken as controls after matching the age and sex. The patients were selected from Dermatology outpatient Department of Universal College of Medical Sciences Teaching Hospital, Bhairahawa, Nepal. The serum zinc level was measured using spectrophotometry principle.

Results: The mean serum zinc level in the cases and controls were 80.50±37.24 mg/dl and 104.31±25.31 mg/dl respectively. Significant difference in serum zinc level was observed between cases and controls (p=0.0001). There was a strong association between low serum zinc level and cutaneous viral warts (OR=7.37; 95% CI=1.98 – 27.31; p=0.0028).

Conclusion: Serum zinc level in patients with cutaneous viral warts was significantly low as compared to the healthy controls.

Keywords: Immune system, micronutrients, papillomaviridae, warts, zinc

Profile of Clients of HIV Testing and Counseling in a Tertiary Care Center and Need of Testing in Tuberculosis

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23251

Introduction: Sexually transmitted infection is public health issue that amplifies HIV burden globally. At National Center of AIDS and STD Control, annual reported STI are rising steeply recently. Incidence of HIV is 0.03% while prevalence in adult population is less than 1%. National HIV testing guidelines 2017 recommends HIV tests should be performed in tuberculosis and medical conditions. However, it is not routinely done in Nepal.

Objective: To assess profile of STI and HIV among patients attending HIV testing and counseling center of tertiary hospital, and to assess fraction of tuberculosis patients undergoing HIV testing.

Materials and Methods: All patients attending HIV testing and counseling center were tested for HIV. Tests for STI were done based on patient symptoms. Data collected were analyzed with SPSS.

Results: Suspected STI (41.1%) was commonest cause of HIV testing. Among STI, gram positive diplococcic were noted in 11.5% and 3.4% had PCR positive Chlamydia. Only 19.4% (7 out of 36) of total tuberculosis patients in hospital were screened for HIV, among which, 57.14% (4 out of 7) were seropositive for HIV, which is noteworthy.

Conclusion: Our study shows patterns of STI, and that gonorrhea and chlamydia could be underdiagnosed in Nepal. Every patient with tuberculosis should routinely be screened for HIV. But only small fraction of tuberculosis patients underwent HIV screening, out of which HIV positivity was high, reflecting the gap and need for routine HIV screening in TB patients.

Keywords: Acquired Immunodeficiency Syndrome, HIV infections, Sexually Transmitted Diseases, Tuberculosis

Is Latent Syphilis New Normal among Clinical Presentations of Syphilis? Study from a Tertiary Care Institute

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23247

Introduction: Clinical presentation of syphilis varies widely according to stage of syphilis. Latent syphilis pose special challenge for diagnosis as patient is usually asymptomatic and still infectious.

Material and Methods: Retrospective analysis of Rapid plasma reagin (RPR) positive patients over two years duration from tertiary care institute was carried out.

Results: A total of 32 RPR positive patients were analyzed. Eleven (34.37%) patients had clinical features suggestive of Syphilis, rest 21 (65.63%) patients were found to be positive by RPR without any clinical signs and symptoms. Seven patients (21.8%) had genital ulcerative diseases at the time of presentation.

Conclusion: Our study reports rise in incidence of latent syphilis.

Keywords: Genitalia, Sexually Transmitted Diseases, Syphilis, latent

Clinico-epidemiological Profile of Women with Non-venereal Vulval Diseases: A Hospital-based Observational Study

2019-05-30T16:26:21+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23250

Intorduction: Vulval disorders can be of venereal and non-venereal etiology. Establishing non-venereal causation of vulval disorder helps in alleviating fears in patients with the condition. These patients are better dealt in a multidisciplinary clinic as patients with these disorders frequently visit dermatologists and gynecologists for the treatment.

Objectives: To study the clinico-demographic profile of women with non-venereal vulval disorders and to determine their relative frequency.

Materials and Methods: This is an observational, descriptive study done at the Departments of Dermatology and Venereology and Gynecology and Obstetrics, Nepal Medical College Teaching Hospital. All consenting female patients with problems pertaining to female external genitalia were recruited for the study after excluding venereal diseases. Details of the patients were obtained and entered in a predesigned proforma.

Results: Seventy-five females were recruited during a period of 20 months with a mean age of 34.79±17.90 years. Majority were married, uneducated and homemakers. Duration of disease ranged from 3 days to 35 years. Itching was the commonest presenting complaint (82.67%) followed by redness (32.00%), burning sensation (26.67%), white lesions (24.00%) and pain (24.00%). Commonest diagnosis was lichen sclerosus (17.33%), followed by candidiasis (14.67%). Patients presenting with vulval symptoms without lesions were diagnosed with non-specific vulval pruritus (9.33%) and vulvodynia (2.67%).

Conclusion: Itching is the most common presenting complaint and contrary to the popular belief, inflammatory disorders especially lichen sclerosus, rather than infections were common diagnoses in females with non-venereal vulval disorders.

Keywords: Lichen Sclerosus et Atrophicus, Pruritus Vulvae, Vulvodynia

Pattern of Pediatric Dermatoses in a Tertiary Referral Centre, Nepal

2019-05-30T16:26:21+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23249

Introduction: Dermatological problems constitute at least one third of all outpatient visits to a pediatrician and similar number of all visits to a dermatologist involve children.Children are often exposed to climatic and social conditions that make them more likely to develop skin infections and skin injuries.Little is known about the impact of pediatric skin disease on health care systems in developing countries like Nepal. So, data on this study can be useful in monitoring changes in disease trends in children and planning health care programs.

Objectives: To know the current status of disease trends and ethnic distribution of common dermatoses among children (hospital based) in this geographical locality.

Materials and Methods: All children, 14 years and below, attending the dermatology out-patient department with any dermatoses were enrolled in the study. The diagnosis was made by dermatologists based on detailed history and appropriate investigations. Patients were divided into four different age groups.

Results: A total of 424 children with skin related symptoms were enrolled in this study. The mean age of this population was 6.30 years and it ranged from 0.05(19 days) to14 years. A total of 146 infective and 278 non-infective dermatoses were encountered as the primary diagnosis. Infections and infestations were the most common group of disorders (34.4%, 146 cases), followed by dermatitis and eczemas (32.5%, 138 cases). Fungal infections were the most common infective conditions (11.6%, 49 cases).

Conclusion: Infections and infestations were the most common etiologic group of disorders followed by dermatitis and eczemas. Fungal infections were the most common infective conditions followed by pyoderma.

Keywords: Eczema, Ethnic Groups, Mycoses, Pyoderma, Nepal, Skin Diseases, Infectious

Cutaneous Manifestations of Thyroid Hormone Disorder

2019-05-30T16:26:21+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23217

Introduction: Thyroid hormone disorder (THD), a major health problem, is associated with a wide range of diseases. One of the organs, which shows this wide range of clinical signs is the skin. Some dermatological findings may be the first symptoms of THD. Therefore, this study was planned to determine various cutaneous manifestations of THD that can be used as a diagnostic marker for THD. In Nepal due to lack of awareness, thyroid diseases may go unnoticed .So, cutaneous manifestations help in early diagnosis and treatment of THD.

Objectives: To identify cutaneous manifestations of THD and to evaluate dermatological manifestations specific for THD.

Materials and methods: Seventy six patients with diagnosis of THD attending endocrine clinic of Internal Medicine Department in BPKIHS, Dharan were consecutively assessed for cutaneous changes by detailed history and clinical examination. As a control group, 26 age and sex matched individuals without THD were included to assess frequency of cutaneous manifestation in normal individuals.

Results: Fifty five (72.3%) cases and 4(15.4%) control had skin changes. This observation was statistically significant with OR-14.4(95% CI4.43 – 46.78) and p<0.001.Hair changes (OR-2.100, 95% CI 0.647-6.821 and p=0.210) and nail changes (OR-1.818, 95% CI 0.371-8.902 and p=0.726) had no statistically significant association with THD.

Conclusion: THD may present as or be associated with many changes in skin, hair and nails.

Keywords: Cutaneous changes, Hypothyroidism, Hyperthyroidism

Role of Anti-oxidants in the Treatment of Vitiligo

2019-05-30T16:26:21+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23132

Introduction: The role of free radicals and oxidative damage in the pathophysiology of vitiligo has been documented in recent studies. Antioxidant supplementation has been reported to be useful in the treatment of vitiligo.

Objective: To evaluate the role of oral antioxidants supplementation therapy in the treatment of vitiligo by assessing the onset of repigmentation and oxidative stress.

Materials and Methods: A total of 80 cases of vitiligo randomized into two groups: antioxidant and placebo comprising 40 patients each and were followed up for 8 weeks for the assessment of onset of repigmentation of vitiliginous lesions as primary outcome. The activities of Malondialdehyde (MDA), Vitamin C, and Vitamin E in serum and of Catalase (CAT) in erythrocytes of patients at baseline and at end of eight weeks were also assessed by using the spectrophotometric assay.

Results: The onset of repigmentation was noted significantly earlier among the anti-oxidant group as compared to the placebo group (p=0.015). At the baseline, between the two groups, no significant difference was found in the different biochemical parameters. However, at the end of 2 months the level of MDA (p<0.001) was found to be significantly lower and that of Vitamin E (p<0.001) and CAT (p=0.005) was significantly higher among the anti-oxidants group as compared to the placebo group.

Conclusion: Antioxidant supplementation carried a better response in terms of early onset of repigmentation and significant decrease in the oxidative stress, in the short follow up of two months.

Keywords: Anti-oxidants, Vitiligo, Oxidative stress

Spectrum of Dermatological Manifestations among Travelers Presenting at aTravel Medicine Center in Western Nepal

2019-05-30T16:26:21+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23386

Introduction: Skin disorders are among the most common reasons for travelers to seek medical care during and after travel. There is limited data on the spectrum of dermatoses reported among travelers during travel especially in South Asian continent.

Objective: To review the spectrum of skin disorder manifested among the traveler population attending a travel medicine hospital in western Nepal.

Materials and Methods: We performed a prospective study of the travelers visiting The Canadian International Water and Energy Consultants (CIWEC) Hospital, and Travel Medicine Center in Pokhara with history of skin disorders. This study was done from September 2014 until December 2015.

Results: A total of 130 (14.7%) patients presenting with dermatological manifestations were enrolled in the study. The most common diagnoses were bacterial skin infections 0.4%, arthropod bites 3.6% followed by animal bites and skin laceration due to trauma,each were 12.1%. Among patients with bacterial skin and soft tissue infections, pus culture and sensitivity were recorded in 13 patients. In almost fifty percent of our sample Staphylococcus aureus growth was seen, of which 38.5% were Methicillin Resistant Staphylococcus aureus.

Conclusion: Bacterial skin and soft tissue infections, arthropod bites and animal bites were common reasons for travelers to seek medical consultations during travel in Nepal. This information will be useful for the medicine professionals while taking care of travelers and also while providing pre-travel consultation to the prospective travelers.

Keywords: Nepal, Skin diseases, Staphylococcus aureus, Travel medicine

Leprosy in Post Elimination Period: An Experience in a Single Tertiary Care Centre in Kathmandu, Nepal

2019-05-30T16:26:21+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23388

Introduction: Leprosy elimination was declared by Government of Nepal almost a decade back.

Objective: To evaluate the clinical and epidemiological profiles of leprosy patients in post elimination period

Material and Methods: Analysis of medical records of all clinically diagnosed and newly registered cases of leprosy attending Dermatology outpatient department of Tribhuvan University Teaching Hospital, Kathmandu, Nepal from 1st April 2017 to 31st March 2018 was done.

Results: Hospital based prevalence of Leprosy was found to be 0.24%, with males outnumbering females (63.6% vs 36.4%).The most common age group affected was 45-59 years with hypo-aesthetic patches/plaques and erythematous anaesthetic /hypoaesthetic patches (36.4% each) being the most common presentation. Overall, borderline leprosy was the most common diagnosis (borderline tuberculoid ,29.5% , borderline borderline, 6.8%, borderline lepromatous,11.36%). Slit skin smear positivity was found in 50% of cases.

Conclusion: Leprosy still remains a challenge for clinicians in Nepal though elimination has been achieved. A constant evaluation, monitoring and case detection should be still pursued with health education in order to make timely diagnosis and prevent deformities.

Keywords: Leprosy, Nepal, Public health

Granuloma Multiforme: First Report from Nepal

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23292

Granuloma multiforme (GM) is a reactive skin disorder of unknown etiology, characterized clinically by confluent annular lesions and histologically by focal necrobiosis and histiocytic granulomas. GM is significant because it mimics various conditions and diagnosis is often missed if not taken into consideration. Here, we report a case of granuloma multiforme from Nepal in a 40 year old female with multiple skin colored to mildly erythematous, occasionally itchy annular plaques of duration 6 months, over the upper back and upper chest. Histopathology helped to clinch the diagnosis and differentiate from similar clinical and histologic mimics.

Keywords: Granuloma, Necrobiotic disorders, Nepal, Skin

Sporadic Progressive Symmetric Erythrokeratoderma: Classical Presentation of a rare Condition

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23293

Progressive symmetrical erythrokeratodermia (PSEK) is a rare autosomal dominant genodermatosis presenting in infancy or early childhood. An 11-year-old male presented with a history of pruritic, erythematous, scaly, hyperkeratotic plaques first noted at 5 years of age, with no history of similar lesions in the family. Cutaneous examination revealed multiple, irregularly shaped, erythematous plaques with fine, shiny white, adherent scaling distributed symmetrically over the face, trunk, inguinal area, bilateral axillae and extensor surfaces of limbs. Palmoplantar keratoderma was present with thickened, yellowish discolored nails. No systemic abnormality was found. The histopathological findings were consistent with PSEK. The case is being reported to increase the awareness about this rare disease.

Keywords: Genetic Heterogeneity, Keratoderma, palmoplantar, Nepal, Retinoids

Iatrogenic Cushing Syndrome due to Application of Potent Topical Corticosteroid: A Case Report

2019-05-30T16:26:20+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.23291

Corticosteroids are over the counter and cheaper drugs available in every medical stores in Nepal. Iatrogenic Cushing syndrome due to topical steroids application is a very rare phenomenon in adults.A 32 year female from Janakpur presented with complaints of swelling of face, weight gain, excessive facial hair and fatigue since two years that gradually increased over last one year. She had a past medical history of on and off application of multiple potent topical corticosteroids for disseminated Tinea infection. She was obese with moon facies, buffalo hump and multiple striae over her abdomen. Her blood pressure was raised and her blood sugar was in pre-diabetic range. Laboratory studies were consistent with iatrogenic Cushing syndrome. Patient recovered after discontinuation of topical corticosteroids and treatment with antifungals.Although iatrogenic Cushing syndrome following application of topical corticosteroid is a rare phenomenon in adults, this can happen in a setup like ours where corticosteroids are prescribed as over the counters and patients have very little knowledge about their use. Therefore, we emphasize that patients and pharmacist should be well educated about the consequences of their prolong application and their side effects.

Keywords: Adrenocorticotropic hormone, Clobetasol, Pituitary-adrenal system

Multiple Non- Familial Trichoepitheliomas in a NineYear Child

2019-05-30T16:26:21+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.21119

Trichoepitheliomas are rare benign tumours of poorly differentiated trichogenic origin. They present as translucent lesions most commonly on centrofacial regions. Solitary lesions are seen in sporadic cases while multiple lesions are inherited in autosomal dominant pattern. We present a 9 year old child with multiple trichoepitheliomas at classical sites with none of the other family members involved.

Keywords: Adalimumab;, Genes, Suppressor, Hair Follicle

Generalized ILVEN or Blaschkoid Psoriasis: A Persistant Dilemma

2019-05-30T16:26:21+00:00

DOI: https://doi.org/10.3126/njdvl.v17i1.22048

A 24-year-old man presented with itchy verrucous, scaly red-brown papules, & linear plaques distributed in a blaschkoid pattern all over the body since last 20 years associated with itching. A skin biopsy was consistent with ILVEN (inflammatory linear verrucous epidermal nevus). Histopathologically, it can be difficult to distinguish it from linear psoriasis. It may respond to conventional anti-psoriatic therapies like potent topical corticosteroids applied under occlusion, or systemic treatments like acitretin.

Keywords: Interleukin-1, Isotretinoin, Musaicism, Nevus, Psoriasis