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   Table of Contents - Current issue
Coverpage
July-December 2020
Volume 24 | Issue 2
Page Nos. 65-142

Online since Tuesday, November 10, 2020

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EDITORIAL  

Can changing skin pH help us control atopic dermatitis? p. 65
Kayla H Felix, Courtney E Heron, Steven R Feldman
DOI:10.4103/jdds.jdds_118_20  
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REVIEW ARTICLES Top

Cutaneous manifestations of human immunodeficiency virus/acquired immunodeficiency syndrome: A comprehensive review p. 66
Daniel J Lewis, Steven R Feldman
DOI:10.4103/jdds.jdds_75_20  
Background: Cutaneous manifestations of human immunodeficiency virus (HIV) may be among the initial signs of HIV-related immunosuppression. As such, recognizing HIV-related cutaneous manifestations may lead to the early diagnosis of HIV infection, enabling the prompt initiation of antiretroviral therapy. Purpose: The objective of this article is to discuss the disease history, clinical findings, serologic findings, and treatment options of cutaneous manifestations of HIV. Methods: A nonsystematic review of the literature was performed using PubMed/MEDLINE and Scopus from which relevant articles were analyzed and summarized in the article. Results: There are a number of dermatologic conditions associated with HIV infection, which can be grouped into various categories: acute HIV infection, bacterial infections, viral infections, fungal infections, parasitic infections, papulosquamous dermatoses, eczematous dermatoses, and miscellaneous disorders. Skin-related disorders observed in HIV may result from the viral infection itself or from opportunistic infections or skin disorders secondary to the immunocompromised state inherent to the infection. Many associated skin diseases are more severe in HIV-infected patients, particularly those with severe immunosuppression as seen in acquired immunodeficiency syndrome. Conclusion: Prompt recognition of these skin manifestations is critical to the initiation of disease-modifying antiretroviral therapy.
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Intralesional corticosteroid injections for the treatment of oral lichen planus: A systematic review p. 74
Aliyah Alsubhi, Noura Salem, Maryam Mohab, Bashaer Alghamdi, Nouf Alghamdi, Raniya A Alasiri, Rajwa A Sindi, Raneem A Almastadi, Noor M Alfayez, Mawaddah Alsulaimani, Weaam Alsheikh, Sana Alhamed, Hani Mawardi
DOI:10.4103/jdds.jdds_76_19  
Background: Oral lichen planus is a chronic, immune-mediated disease that can impact the oral cavity significantly. Treatment options include topical and systemic corticosteroid therapy based on the disease severity. Intra-lesional corticosteroid injections (ILCI) have been incorporated in clinical practice as an effective modality to deliver treatment locally to expedite the healing process while limiting systemic toxicity. Purpose: The objective of this systematic review was to evaluate the role of ILCI in treating OLP. Methods: A systematic review of the literature was conducted in the PubMed and Web of Science databases following PRISMA protocol and up to September 2019. All English-language literature on ILCI for OLP was included. Relevant articles were systematically reviewed using multiple levels of elimination by title, abstract, and full text. Data from the included studies were extracted and analyzed. A total of six studies met the inclusion criteria. Results: Triamcinolone acetonide intra-lesional injection demonstrated efficacy and rapid healing of OLP lesions in three studies. Minor adverse events of secondary oral candidiasis and cushingoid features were reported. Conclusion: ILCI may be considered as an effective treatment option for OLP lesions with minimal side effects and risk of disease relapse.
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Does psychological stress trigger or exacerbate vitiligo: More data are needed p. 81
Seba N Almutairi, Mohammed I Aljasser
DOI:10.4103/jdds.jdds_26_19  
Background: Vitiligo is a common disorder characterized by depigmentation due to autoimmune destruction of melanocytes. The role of psychological stress in causing vitiligo is not well characterized. Purpose: This article aims at reviewing the role of stress in triggering and/or exacerbating vitiligo. Methods: Seven relevant studies were found in the literature search. Results: Most of the studies support the theory that stressful life events may trigger the onset or the progression of vitiligo. Conclusion: Studies depended mainly on retrospective reporting of stressful events could be a major source of bias.
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ORIGINAL ARTICLES Top

Skin pH and its relationship with transepidermal water loss and disease severity in children with atopic dermatitis: A cross-sectional study p. 84
Choon S Lee, Adawiyah Jamil
DOI:10.4103/jdds.jdds_33_20  
Background: pH is increasingly a target in therapeutic strategies for skin barrier repair, but the relationship between pH, transepidermal water loss (TEWL), and atopic dermatitis (AD) severity is not well characterized. Purpose: The purpose of the study was to determine the relationship between skin pH with TEWL and their correlations with AD severity. Methods: A cross-sectional study enrolled children aged 4–12 years with AD. Measurements were made using HI 99181 and Tewameter TM 300 at two lesional sites and two nonlesional sites (left cubital fossa, left thigh, and forehead). Disease severity was evaluated using the Eczema Area and Severity Index (EASI) and pruritus score. Results: A total of 14 (58%) girls and 10 (42%) boys aged 7.3 ± 2.6 years with age of AD onset 3.0 ± 2.1 years participated. The mean EASI score was 8.9 ± 8.2, body surface area 13.1% ± 18.5%, pruritus score 5.9 ± 2.7, and Children Dermatology Life Quality Index 5.6 ± 4.9. pH and TEWL were higher at lesional compared to nonlesional skin, pH 5.2 ± 0.7 versus 4.6 ± 0.4, P < 0.01 and TEWL 31.1 ± 15.2 versus 16.0 ± 10.2, P < 0.01. Lesional pH positively correlated with TEWL (r = 0.59, P= 0.02 and r = 0.55, P = 0.01), while nonlesional pH was inversely correlated (r = −0.42,P = 0.04 and r = −0.40, P = 0.05). pH showed significant positive correlations with EASI and itch at one lesional site. Conclusion: pH and TEWL were higher at lesional skin. pH correlated positively with TEWL at lesional skin but inversely at nonlesional areas. Higher pH was associated with disease severity and itch. pH restoration may have therapeutic potential in AD.
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Nail manifestations in cancer chemotherapy: A cross-sectional study p. 88
Zainaba Mizaj, Spandana P Hegde, Guruprasad Bhat, Vishal B Amin, Malcolm Pinto, Manjunath M Shenoy
DOI:10.4103/jdds.jdds_79_20  
Background: Anticancer chemotherapy is associated with multisystem adverse effects. Chemotherapy can affect skin, nails, and hair and may sometimes affect the quality of life to the point of requiring discontinuation of therapy. There are many new chemotherapeutic agents, and with that, a rise in the adverse effects attributed to them. Purpose: To evaluate the frequency of nail changes occurring due to anticancer therapy. Methods: We screened 100 cancer patients admitted in the oncology ward of a tertiary care center in South India from July to September 2017. The nail changes were documented and analyzed with emphasis on developing a relationship if any with a chemotherapeutic agent. Results: Nail changes were observed in 62 (62%) cases. Breast carcinoma (20 cases) was the most common malignancy. Doxorubicin (36 cases) and cyclophosphamide (27 cases) were the most common chemotherapeutic drugs associated with nail changes. Pigmentary changes (32 cases) were the most common nail plate changes. Blue lunula (24 cases) was the most common nail bed change, occurring with cyclophosphamide/doxorubicin. Pyogenic granuloma was the only nail fold change that was noted in a patient of carcinoma of breast treated with gefitinib. Conclusion: Cancer chemotherapy may be associated with a variety of nail changes. Addressing nail changes may have the potential to improve cancer treatment patients' quality of life.
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Surgical wound dehiscence following cutaneous excisions: A retrospective study and review of the literature p. 93
Jennifer Seyffert, Tanner Harding, Asmi Sanghvi, Nathan Bibliowicz, Martin Yungmann, Shawn Camner, Matthew Leavitt, James A Solomon
DOI:10.4103/jdds.jdds_71_20  
Background: Surgical wound dehiscence (SWD) is the third most common adverse event following dermatologic surgery. There have been no previous studies investigating risk factors for SWD following dermatologic surgery. There are no formal recommendations or standards of care to minimize or prevent SWD following dermatologic surgery. Purpose: The purpose of this study was to identify risk factors associated with dermatologic SWD. Methods: Multicenter retrospective data mined from EMA electronic medical record were collected from 22,548 matched excisions and postoperative visits performed on patients ≥18 years between January 1, 2019, and September 27, 2019. Matched data analysis was performed using IBM SPSS Statistics 25 to elucidate factors associated with SWD. Results: The prevalence of SWD was calculated to be 0.55%. A wound reported as positive for presumed infection or postoperative bleeding had 14.48 and 20.15 times the odds, respectively, of also being positive for SWD. A wound located on distal extremities (arm, hand, and lower leg) had 1.86 times the odds of being positive for SWD. Increasing age was found to be statistically significant. Wounds on individuals 80 years of age or greater had 1.7064 times the odds of being positive for SWD. Data did not support a correlation between SWD and sex, SWD and diabetes, or SWD and provider type. Conclusion: Factors that contribute to SWD dehiscence include presence of presumed infection, presence of bleeding, age >80, and location on the distal extremity. Data did not support a correlation between SWD and sex, SWD and diabetes, or SWD and provider type. Dermatologic surgeon identification and reduction of risk factors contributing to this adverse event may prevent SWD.
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Clinical and epidemiological profile of libyan patients with mycosis fungoides: A prospective study p. 99
Nadia A El Sherif, Abdulhamed A M. Elorfi, Omarn O Bugrein, Soad I Eldruki
DOI:10.4103/jdds.jdds_24_20  
Background: Mycosis fungoides (MF) represents the most common form of primary cutaneous T-cell lymphoma (CTCL) often with an indolent course. Purpose: The objective is to determine epidemiological and clinical features of MF among Libyan patients. Methods: Clinical and histopathological evaluation was carried out in 24 patients with MF in the Department of Dermatology at El-Jumhoria Hospital in Benghazi city between 2010 and 2019. Results: Twenty-four patients with a diagnosis of MF, 11 were female and 13 were male. Age of the patients ranged between 30 and 60 year with a mean of age ± standard deviation of 47.4 ± 8 years. Clinical presentation with patches and plaques was most common, seen in 58.3% of the patients. Poikilodermatous MF was seen in 37.5% patients, hypopigmented MF seen in 12.5% of patients, follicular MF seen in 8.3% of patients, and 8.3% patients had lymphomatoid papulosis. Pruritis was the complaint of 75% of the patients. About 25% of the patients had blood eosinophilia, 33.3% had raised lactic dehydrogenase enzyme. Tumor-node-metastasis-blood (TNMB) classification of the patients revealed that 66.7% had stage IB, 20.8% of patients had stage IIA, 8.3% of patients had stage IIB, and 4.2% patients had stage IVa. About 70.8% of patients received systemic Psoralen and ultraviolet A (PUVA) therapy, 20.8% patients received narrow band ultraviolet B, 4.2% patients treated with radiotherapy, and 4.2% patients received both chemotherapy and radiotherapy. About 45.8% of patients show remission of their disease, 12.5% patients show no response, 8.3% of patients still under treatment, 25% of patients lost follow-up, and 8.3% patients died. Conclusion: MF is a low-grade primary CTCL with different clinical presentations with variable response to therapy.
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Pattern of skin cancer in Saudi patients at King Abdulaziz Medical City in Riyadh, Kingdom of Saudi Arabia between 2005 and 2015: A retrospective study p. 105
Sultan Al Qahtani, Rawan Aldahash, Najd BinManie, Mohammed Al Assiri
DOI:10.4103/jdds.jdds_18_20  
Background: Skin cancer is one of the most common among white-skinned individuals. Its prevalence depends on geographic and ethnic variations. The pattern of skin cancer in Saudi patients per province is not well-established. Purpose: This retrospective study evaluated the pattern of skin cancer among Saudi patients from Riyadh area who have visited King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia, between the years of 2005 and 2015. Methods: Data from 300 cancer patients were collected from KAMC and analyzed with respect to age, sex, cancer type, and cancer location. Results: Except for mycosis fungoides (MF), all other studied skin cancer types were more common in males as compared to females (1.56:1). Among the study population, the majority of skin cancer cases were seen in patient who aged more than 40 years old (86%) with the highest rate to be among those who are between 60 and 79 years old. Among all cases, the pattern and ratio of various skin cancers were as follows: Basal cell carcinoma (BCC) (45.7%), squamous cell carcinoma (SCC) (14.7%), MF (7.3%), and malignant melanoma (MM) (7%), followed by sebaceous adenocarcinoma (SC), Kaposi sarcoma, and dermatofibrosarcoma protuberance each of 4.3%. With respect to cancer location, 141 cases were located on the face (46.95%), 46 on the hips and lower limbs (15.26%), 44 on the chest and abdomen (14.8%), 28 on the scalp and neck (9.29%), 21 on the shoulders and upper limbs (6.95%), and 17 were unspecified. Conclusion: Among Saudi patients with skin cancer in the central region of the Kingdom of Saudi Arabia (KSA), BCC and SCC were the most common cancers, followed by MF and MM. Further studies are needed to fully determine common risk factors among these and future cases.
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Intralesional measles, mumps, and rubella vaccine versus cryotherapy in treatment of warts: A prospective study p. 110
Harish M Rajegowda, Deepadarshan Kalegowda, Shashi K B. Madegowda, Jayashree K Palanayak
DOI:10.4103/jdds.jdds_60_20  
Background: Warts are benign tumors caused by infection of keratinocytes with human papillomavirus. Various modalities are available for the treatment of cutaneous warts such as destructive procedures, surgical methods, and immunotherapy. Recently, immunotherapy with intralesional antigens/vaccines is emerging as a novel method with encouraging results. Purpose: The study aimed to compare the efficacy of intralesional mumps, measles, and rubella (MMR) vaccine versus cryotherapy in the treatment of cutaneous warts. Methods: In this prospective study, 60 clinically diagnosed cases of cutaneous warts were enrolled and randomly divided into two groups of 30 each. Patients of Group A received 0.5 ml of reconstituted MMR vaccine, which was injected into the largest wart. The dose was repeated at 3-week intervals until complete clearance or for a maximum of 3 doses. In Group B, patients received cryotherapy with liquid nitrogen at weekly intervals for a maximum of 9 sessions. Patients of both the groups were followed up at the 3rd, 6th, and 9th weeks to evaluate clinical outcome on the Visual Analog Scale. Statistical analysis was done by the Chi-square test using SPSS software. Results: Out of 30 patients, 63.3% (19) of the patients of Group A showed complete clearance of warts compared with 33.3% (10) of the patients of Group B at the end of 9 weeks. Adverse effects were more with cryotherapy including pain, blistering, and depigmentation, whereas immunotherapy was well-tolerated except for the pain during injection. Conclusion: Intralesional MMR vaccine immunotherapy was more effective, with an added advantage of regression of distant warts, fewer sessions, and no serious side effects.
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Accuracy of diagnoses of skin diseases in a pediatric emergency room: A retrospective study p. 116
Suzan A AlKhater
DOI:10.4103/jdds.jdds_72_19  
Background: Cutaneous disorders are common in children. Few studies have assessed the diagnostic accuracy of pediatricians in diagnosing skin disorders. Purpose: In this study, the accuracy of the diagnoses of skin diseases made in a pediatric emergency room (ER) was determined. Methods: Data were obtained from a retrospective study of children with dermatological disorders seeking emergency services in the pediatric ER in a teaching hospital in Saudi Arabia. Descriptive statistics were used to determine the distribution of patients and time characteristics. Crude and adjusted logistic regression models, controlling for demographic and time-associated characteristics, were used to determine the association between clinical and other characteristics and diagnostic accuracy of pediatricians. Results: There were statistically significant differences in the overall distribution of the study population by gender, season, time of week, shift, and referrals (P < 0.05). After adjusting for these factors, every unit increase in age (years) was associated with a 38% increase (odds ratio: 1.38; 95% confidence interval: 1.18–1.61) in the odds of pediatricians being likely to have the correct diagnosis. There were significant differences between the diagnosis made by pediatrician and the final diagnoses made by senior staff (P < 0.001). Infections and neonatal skin diseases were underdiagnosed, while overdiagnoses of allergic and hypersensitivity reactions were observed. Conclusion: The results emphasize the importance of orienting pediatric trainees on the dermatological aspects of diseases, particularly on the topics involving infectious, allergic and hypersensitivity reactions, and neonatal skin disorders. This points out the importance of making dermatology rotation as a core requirement during the residency training rather than just optional electives.
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The clinico-epidemiological profile of alopecia areata: A hospital-based study in Jeddah, Saudi Arabia p. 122
Taghreed T Mahjoub
DOI:10.4103/jdds.jdds_77_19  
Background: There is a paucity of the epidemiologic studies of alopecia areata (AA) in Arab countries, especially from Saudi Arabia. Purpose: The aim was to describe the epidemiological and the clinical features of AA and its associated disease in Jeddah, Saudi Arabia. Methods: A retrospective review of medical records of 83 patients with AA seen at King Abdulaziz Medical City, Jeddah, was performed between July 2017 and July 2018. AA was classified into mild (with <10% scalp involvement and AA limited to beard area), moderate (patchy AA with <50% scalp involvement), and severe (alopecia universalis, ophiasis, alopecia totalis, and patchy AA with ≥ 50% scalp involvement). Results: The most common types of AA were mild patchy AA with <10% scalp in 35 (42.2%) patients, followed by AA limited to beard area in 24 (28.9%). The most common associated disease was atopic dermatitis which was seen in 10 (12%) patients, followed by thyroid disorder in 9 (10.8%). The most common treatment was intralesional corticosteroid (79.7% of mild and 83% of moderate) for mild and moderate and diphencyprone for severe AA (44.4%). Conclusion: Early age of onset is associated with more severe AA. The most commonly associated diseases are atopic dermatitis and thyroid disorder.
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Self-use of skin-bleaching products among women attending a family medicine clinic: A cross-sectional study p. 125
Zinab A Alatawi, Mohammed ALShahrani
DOI:10.4103/jdds.jdds_13_18  
Background: The use of skin-lightening creams is common and widespread in African, Asian, and North American colored no brown to dark. Use of skin-bleaching agents has been reported in Saudi Arabia. The long-term use of these products for several months to years may cause cutaneous or systemic side effects. Purpose: This study aimed to assess the prevalence of self-use of skin-bleaching agents among Saudi women as well as the level of awareness, attitudes, and practice toward the use of these agents. Methods: A cross-sectional study was conducted by the selection of systematic random sampling of female attending the Family Medicine Clinic at Prince Mansour Military Hospital. The data collected by a structured questionnaire included information about background variables and attitudes, awareness, and practice regarding the use of skin-bleaching agents. The data were analyzed using statistical software to yield descriptive and inferential statistics. Results: A total of 358 women aged between 18 and 55 years were included in this study. Nearly 25% of the women were current users of skin-bleaching agents, while 39.6% were only previous users. About a third of women used bleaching creams in the treatment of hypo or hyperpigmented skin and 29.4% used them for cosmetic purposes. Regarding the source of these agents, 38% of women obtained them by medical prescription and 27.8% were from pharmacy without prescription. The reason for using skin-bleaching creams varied: 51.6% of females used creams to increase beauty, 51% for making a new look, 6% for increasing self-confidence, and 4.3% to increase the stability of marriage. Almost 56% of the women reported that cortisone is the most dangerous component in the skin-bleaching agents. Nearly 33% of the women reported being willing to use a quick whitening agent from an unknown source. Higher education and higher income were associated with greater use of skin-lightening creams. Conclusion: The lifetime use of skin-bleaching agents was relatively high, divided evenly on cosmetic and curative purposes. The level of awareness about these agents is low because a considerable proportion of respondents agreed to use agents from unknown sources, in addition to the high use of skin-bleaching agents obtained without medical or pharmacist consultation.
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CASE REPORTS Top

Unilateral pachydermodactyly in a Saudi boy: A rare presentation p. 130
Lamia Al Akrash, Alanoud Al Huqayl, Ahmed Al Humidi, Abdulrahman Al Jamal
DOI:10.4103/jdds.jdds_8_19  
Pachydermodactyly (PDD) is a rare, acquired idiopathic form of digital fibromatosis. PDD typically presents as asymptomatic swelling of the second to fourth proximal interphalangeal joints bilaterally in young males. Here, we present an acquired unilateral PDD in a Saudi boy with emphasis on the clinical, radiological, and histopathological features. In conclusion, PDD is a benign disease; a prompt recognition would prevent irrelevant workup and reassure patients.
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Effectiveness of adalimumab in combination with intense pulsed light and radiofrequency therapy (LAight®) for severe hidradenitis suppurativa: A case report p. 133
Uwe Kirschner, Berenice Maureen Lang, Kerstin Steinbrink, Sophia Zimmer
DOI:10.4103/jdds.jdds_36_19  
Hidradenitis suppurativa (HS also named as acne inversa) is a chronic skin disease characterized by relapsing formation of abscesses, inflammatory nodules, and fistulas. In moderate-to-severe disease, HS leads to the formation of scarring and thus irreversible tissue destruction. In the past few years, two new treatment options became available: adalimumab, the first biologic therapy approved for HS (Humira®, AbbVie), and a noninvasive, device-based treatment utilizing a combination of intense pulsed light and radiofrequency (LAight® therapy, LENICURA, Germany). Here, we report a case of a Hurley stage III patient where the positive effect of adalimumab could be enhanced by simultaneously applying LAight® therapy. Moreover, long-term symptom control could be achieved under monotherapy with LAight® after adalimumab was terminated.
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Infantile granular parakeratosis: Case report and review of the literature p. 135
Hanan M Almeshal
DOI:10.4103/jdds.jdds_28_20  
Granular parakeratosis (GP) is a benign skin disease that has been reported in adults and children. Lesions usually affect the axillae, groin, and submammary region. The primary lesions present as brown keratotic papules and can form plaques. The etiologies implicated in the development of GP include the use of topical cream and the use of deodorants, local irritation and in children, it was linked to repetitive washing of the affected area and the use of zinc oxide cream. This is a case report of GP in a 14-month-old boy noted after washing the groin area with soap and using zinc oxide cream. The lesions have improved after the discontinuation of the use of zinc oxide cream and soap in washing the affected area.
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Atypical Stevens–Johnson syndrome caused by pembrolizumab in the treatment of metastatic melanoma – Are corticosteroids a safe treatment option? p. 137
Cathal OConnor, Emmet Jordan, Michael O'Connell
DOI:10.4103/jdds.jdds_73_20  
Pembrolizumab is a humanized monoclonal antibody that targets programmed cell death receptor-1. Stevens–Johnson syndrome (SJS) secondary to pembrolizumab has rarely been described in the treatment of malignant melanoma (MM). A 62-year-old woman developed a widespread bullous eruption following administration of her third dose of pembrolizumab for the treatment of MM. A skin biopsy showed sub-epidermal bulla formation with lymphocytic infiltrate and a necrotic roof, consistent with a SJS/toxic epidermal necrolysis (TEN) disorder. Intravenous methylprednisolone was administered. Upon cessation of oral prednisolone, there was a recrudescence of the eruption. A repeat skin biopsy confirmed recurrent SJS. Following a prolonged taper with oral prednisolone, there was no further relapse of SJS. Severe cutaneous adverse reactions such as SJS/TEN have been reported with pembrolizumab and can be associated with significant morbidity and even mortality. High-dose systemic corticosteroids are frequently used in its treatment. Concerns about the potential negative effect of high-dose steroids have re-surfaced, given the observed reduced overall survival in patients with MM. Due to difficulties in performing studies in this population, the benefits and risk of steroids should be considered on a case-by-case basis.
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Vulvar syringoma – A rare distribution of a common entity: Report of two cases p. 140
B Sathish Pai, Kanthilatha Pai, Varsha M Shetty, Anuradha Jindal, Sandhiya Ramesh
DOI:10.4103/jdds.jdds_25_19  
Syringomas are common benign appendageal tumors arising from eccrine sweat glands. They are commonly encountered in women, appearing as yellowish to skin-colored papules, 1–5 mm in diameter. They are typically distributed around the lower eyelids and malar areas; however, vulvar syringoma occurs rarely. Vulvar syringoma needs to be differentiated from papular eruptions occurring on the vulva. Histopathological examination may be needed to distinguish them from other disorders as clinical examination alone may fail to do so. Herein, we report two cases of vulvar syringomas.
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