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   Table of Contents - Current issue
July-December 2018
Volume 22 | Issue 2
Page Nos. 45-92

Online since Friday, September 21, 2018

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Don't trust what I tell you p. 45
Steven R Feldman
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Electrodermal acupuncture as a marker for aging p. 46
Adrian Pona, Sarah L Taylor, Steven R Feldman
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Hidradenitis suppurativa: A comparison of guidelines p. 48
Verena Isak, Steve R Feldman, Rita O Pichardo
Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the folliculopilosebaceous unit (FPSU) in the intertriginous skin areas, especially axilla, groin, perineum, and peri- or sub-mammary fold in women, with secondary inflammation of eccrine and apocrine glands. HS disease activity and severity can be divided into three different stages according to the Hurley staging system. Stage I disease consists of single or multiple abscesses, while in Stage II, additional sinus tract formation or scarring can be seen, and in Stage III, interconnected tracts and abscesses have developed over a complete anatomic area. Due to its high disease burden, the extent to which HS negatively impacts patients' quality of life is higher than that of most other chronic dermatological conditions. Pain is considered one of the worst aspects of HS. In this article, we compare different guidelines for the management of HS between hospitals in Europe and the U.S. for Hurley Stage I, II, and III. Existing treatment guidelines were identified through systematic review of medical databases, including PubMed, using the search terms “hidradenitis suppurativa treatment guidelines” as well as “acne inversa treatment guidelines” for the European and German treatment guidelines, as well as American hospital-specific treatment algorithms, including Henry Ford Hospital, Detroit, Michigan, and Mayo Clinic, Rochester, Minnesota. In the German S1 guidelines, the goal is an improvement of one Hurley stage and/or a 25% improvement of the Sartorius score or the dermatology life quality index within 12 weeks. Radical surgical or laser excision, oral combination therapy of clindamycin and rifampin, or alternatively tetracycline, topical clindamycin, and hormonal therapy are recommended, while topical resorcinol, dapsone, finasteride, zinc gluconate, and acitretin are the treatment options that can be taken into consideration. Unlike the European or German S1 guidelines or the algorithm proposed by the Henry Ford Hospital, more systemic antibiotic therapy options are suggested in the Mayo Clinic algorithm before the addition of immunosuppressive therapy. Evaluation for efficacy happens every 3 months, and in case of treatment failure, the antibiotic regimen is changed and reevaluated 3 months later. Options include Trimethoprim-sulfamethoxazole, amoxicillin-clavulanate, fluoroquinolones, clindamycin, and rifampin, as well as rifampin plus moxifloxacin plus metronidazole. If none of the proposed antibiotic therapies help, acitretin, dapsone, or cyclosporine may be used instead. In refractory HS, infliximab or adalimumab is added to the regimen. For Stage III disease or in case of treatment failure so far, wide local excision as an addition to medical therapies can be considered. With the literature of the existing treatment options mostly being low evidence, scarce new randomized controlled trials, and the existing guidelines leaving room to interpretation, a gold standard for the treatment of HS does not yet exist. Further large-scale, randomized studies are necessary to continue treatment exploration and improve treatment regimens.
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Electrodermal energy wave at acupuncture points may be a biomarker of aging p. 60
Min Chen, Zhengqin Chen, Qian Liu, Yuwei Pan, Qian Gao, Cangcun Xu, Qincui Zhang, Zhaoqing Xi, Huailiang Zhang
Objective: The main objective is to study the electrodermal energy wave at some acupuncture points on Chinese people with different ages. Methods: The electrodermal screening device MORA-Super (German) was applied to measure the electrodermal energy at 38 acupuncture points and nonacupuncture points on 3949 candidates. Results: There are five groups, including 17 cases ≤12 year, 41 cases between 13 and 18 years, 722 cases between 19 and 39 years, 2995 cases between 40 and 59 years, and 174 cases ≥60 years. The electrodermal energy of candidates older than 60 years increased significantly compared with other groups (P < 0.01). There is positive correlation between electrodermal energy and age (R = 0.582). Conclusion: The electrodermal energy may become a biomarker of aging.
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Outcomes among scalp psoriasis patients: Is scalp psoriasis resistant to topical treatment? p. 64
Toral S Vaidya, Michael E Farhangian, Kathryn L Anderson, Alyson Snyder, Steven R Feldman
Background: Scalp psoriasis is considered notoriously difficult to treat, despite good percutaneous absorption of topical corticosteroids through scalp skin. Poor adherence to treatment is often the cause of poor treatment outcomes. Purpose: Our objective was to gain preliminary assessments of scalp psoriasis treatment outcomes from our patients' perspectives and to assess the feasibility of telephone-based follow-up of scalp psoriasis treatment. Methods: Chart review identified adults seen for scalp psoriasis in the past 3 years. Thirty patients were queried regarding their current disease state, treatment satisfaction, and whether they called the office to report disease progress. Results: Eight-seven percent of the patients reported “doing well” or “moderate improvement;” of these patients, 69% were on only one topical treatment. 90% were on topical treatments alone; of these patients, 93% reported “doing well” or “moderate improvement.” Three of 15 patients who were told to call their provider and report treatment progressfollowed the instruction; those 3 reported “doing well.” Patients given a simple topical corticosteroid treatment regimen and encouraged to report their progress to achieve at least moderate improvement. Conclusions: The dogma that scalp psoriasis treatments are resistant to treatment should be reassessed and larger controlled trials should be done to develop and test adherence interventions to improve scalp psoriasis outcomes.
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Experimental wound ischemia does not promote pseudomonas aeruginosa biofilm formation p. 68
Emi Kanno, Hiromasa Tanno, Kenji Yamaguchi, Ayako Sasaki, Ryoko Maruyama, Masahiro Tachi
Introduction: It has been suggested that wound ischemia is involved in the promotion of bacterial proliferation, which is a detrimental factor in wound healing. Increasing evidence from clinical data suggests that bacteria live within biofilms on nonhealing wounds. Yet, there have been no reports clarifying the contribution of wound ischemia to biofilm formation on nonhealing wounds. Objectives: The present study addresses the question of how ischemia affects biofilm formation at wound sites. Methods: Standardized dorsal ischemic flaps were lifted and sutured on the backs of Sprague–Dawley rats. Partial thickness wounds were created on these flaps, and a suspension of Pseudomonas aeruginosa was applied to each wound. We analyzed wound exudate, histological findings, and biofilm formation. Results: The quantities of exudate from the wounds on the ischemic flaps were greater than those from control wounds. Surprisingly, in ischemic wounds, biofilm formation was diminished and leukocyte infiltration was decreased. Conclusion: Our findings demonstrate for the first time that the ischemic condition may not contribute to the development of biofilm formation on skin wounds through regulating leukocytic responses.
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Follicular unit extraction technique in treating stable vitiligo with leukotrichia p. 72
Arragudla Vikram Kumar, Anchala Parthasaradhi
Background: There are several surgical modalities to repigment vitiligo patches, and follicular unit extraction (FUE) is one among them. This procedure is based on the concept of the presence of undifferentiated stem cells in the hair follicle which are a very good source of melanocytes. These melanocytes spread to the surrounding skin and repigment the epidermis. Materials and Methods: Three cases with few lesions of stable vitiligo over nonglabrous areas were treated with follicular unit grafts using the FUE method. Repigmentation in the vitiligo patches was assessed by subjective analysis. Results: Repigmentation was noticeable in all cases with an average duration of 3 weeks. Almost complete repigmentation was seen in all cases with an average duration of 7.3 weeks. Conclusion: FUE appears to be an effective method in treating vitiligo patches with leukotrichia.
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Suction blister epidermal grafting for neuropathic ulcer in leprosy p. 75
Reeza Edward Yuwantana, Yohanes Widodo Wirohadidjojo
Leprosy is one of the leading causes of chronic wound cases, especially in endemic countries, where the successfulness of disease elimination has not been followed by reduced rates of leprosy-related disabilities. Chronic nonhealing ulcers are often difficult to treat and have a significant impact on the patient's quality of life as well as an economic burden. Suction blister epidermal grafting (SBEG) was invented as an alternative approach for recalcitrant cases with some advantages above conventional skin grafting techniques. However, availability of sophisticated technologies to harvest grafts is a common problem in most facilities in Indonesia along with prohibitive cost for most patients who are below the poverty line. To overcome such limitations, we implemented a simplified SBEG procedure using daily medical instruments and equipments to provide an affordable service to a neuropathic plantar ulcer patient due to leprosy with satisfying result.
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Hidradenitis suppurativa: Presenting at atypical sites p. 79
Sandhya Kumari, Mudita Gupta, Reena K Sharma, Lalita Negi
Hidradenitis suppurativa (HS) is a chronic inflammatory and debilitating disease of apocrine gland-rich areas. Characteristic bilateral involvement of the axilla, perineum, or inguinal folds is a hallmark feature of HS. Certain uncommon sites such as face, neck, jaw region, and legs, which are devoid of apocrine glands, are also involved in some cases. Here, we describe a case of HS involving uncommonly reported sites such as wrist, mid-back, and thigh at initial presentation which were misdiagnosed as scrofuloderma. She later had lesions on less common areas, such as buttocks, and the classical sites, such as groin and axilla, whence a final diagnosis of HS was made. The peculiarity of our case is the onset of disease from atypical sites which are devoid of apocrine glands and terminal hair follicles.
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Distended striae distensae in a patient with nephrotic syndrome p. 82
Archana J Lokhande, Tapan Kumar Dhali, Priya Chaudhary, Rishi Goel, Soni Rathore
Striae distensae (SD) are very common dermatological condition produced as a result of overstretching of skin leading to depressed linear irreversible atrophic dermal scars. We report a case of oral corticosteroid induced extensive striae distensae in a patient with nephrotic syndrome, who developed sudden bulging and fluid collection in these atrophic skin scars during the course of disease. Laboratory analysis of aspirated fluid from the oedematous SD revealed it to be transudate in nature. Thus it was concluded that, as part of anasarca the extracellular fluid got preferentially accumulated within the weaker atrophic scarred skin of striae.
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Localized acneiform eruption induced by radiation therapy p. 85
Bader Sameer Zimmo
Radiation-induced skin changes and dermatoses occur in the majority of patients receiving radiotherapy and may produce significant adverse effects. Radiation-induced acneiform eruption is a rare but likely an underreported cutaneous adverse effect. This is a case of a localized comedonal eruption induced by radiation therapy exposure in a 47-year-old male treated for a malignant tumor. Recognition and proper management of this presentation are important for the optimization of patient health, reassurance of the patient and the treating team, and avoidance of any unnecessary delays in surgical reconstruction planning.
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Exuberant ingrown nail: Satisfactory esthetics results combining surgery techniques p. 87
Edgar Ollague Cordova, Kleber Ollague Cordova, Ana Cecilia Studart, Andreia Leverone, Paula Regazzi, Danielle Quintella
Subcutaneous onychocryptosis is one of the most common diseases of the nail unit. It causes significant morbidity and disability in daily life and may become chronic if not treated. It is classified in three stages as defined by Heifetz and Frost. Conservative treatment is favored in mild cases, while surgery is necessary for stages 2 and 3 ingrown toenails. We describe a case of subcutaneous onychocryptosis Grade III, in which alpha stitch and Howard–Dubois techniques improved final esthetic result. The aim of this article is to present an exuberant case of onychocryptosis and how a combination of surgical techniques can produce a better outcome.
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Follicular occlusion triad Highly accessed article p. 90
Yugal Kishore Sharma, Shivanti Chauhan, Kirti Deo
Follicular occlusion triad is a complex comprising three conditions – hidradenitis suppurativa (HS), acne conglobata, and dissecting cellulitis of the scalp – which share the same underlying pathological process of follicular occlusion. Although these constituents are frequently occurring conditions, the triad per se is not commonly reported. We report the case of a 32-year-old male with Hurley Stage II HS, acne conglobata, and dissecting cellulitis of the scalp with mild anemia (hemoglobin: 10.2 g/dL) and raised C-reactive proteins (15 mg/dL). To the best of our knowledge, this appears to be the third case of follicular occlusion triad from India; also probably, only one case has earlier been reported from India with the additional condition of pilonidal cyst, i.e., a follicular occlusion tetrad.
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