Contents : FROM THE EDITOR’S DESK • From the Editor’s Desk Dr. V. R. Joshi Beauty is but skin deep; so goes the old saying. But not so with skin diseases ! These often go “deeper” and • Guest Editorial are associated with many internal disorders. No wonder Dr. V.R. Mehta skin is called a mirror of one’s health or, shall we say, Dr. Nina Madnani ill health ? • Skin Clues to Systemic Diseases With increasing beauty consciousness and aggressive Dr. Nina Madnani marketing (you can’t be a cricket commentator unless you have a glowing skin ! ref TV ad), skin health has become important. We thought it was • The Adolescent Skin high time we tell our readers the nitty-gritty of skin health. Dr. Nina Madnani Lest in this beauty hype we forget the king of skin diseases and other real • Facial Rejuvenation Sans Surgery diseases, articles on leprosy and others are included. Dr. Nina Madnani As usual our guest editors have spared no effort to make this issue worthwhile. • Diet and Skin Dr. Rajeev Joshi Your comments are welcome ! Dr. V. R. Joshi • Dry Skin Dr. Rajeev Joshi GUEST EDITORIAL • Facial Pigmentation Dr. Rajeev Joshi The word dermatology encompasses diseases of the • Sore Mouth skin, hair, nails, mucous Dr. Rajeev Joshi membranes, and leprosy and • Leprosy sexually transmitted diseases Dr. V. R. Mehta (STDs) including AIDS. Over the years, sub-specialities like Dr. V.R. Mehta Dr. Nina Madnani • Watch That Birth Mark Dr. V. R. Mehta dermatopathology, dermatosurgery, cosmetic dermatology, paediatric dermatology, genital dermatology, etc. have developed. Whereas Editor : dermatology and leprosy have had a clinical orientation, STDs have Dr. V. R. Joshi largely depended on the laboratory for diagnosis. Guest Editors : Traditionally skin diseases have intermingled with internal medicine Dr. V. R. Mehta and each has contributed knowledge to the other. Very often skin Dr. Nina Madnani clues have clinched the diagnoses of evasive clinical conditions for Editorial Board : the physician. Today association with surgery and acquiring technology Dr. Philip Abraham for better treatment is on the ascent and has enhanced our capabilities Dr. Tester F. Ashavaid with the development of various types of lasers, light systems, Dr. Bharat Shah fillers and chemical peels, botulinum toxin, and many more. Dr. Reeta Dalal Most of these are being done at Hinduja Hospital by us. Dr. Soonu Udani The role of cosmetic dermatology to replace/correct unsightly blemishes with normal looking skin is as important today as has Photography : always been. Pramod Tandel Cover Page Source : Gary Garewal & Synergy Creations Contd. on page 4

2 SKIN CLUES TO SYSTEMIC DISEASES Dr. Nina Madnani

In clinical practice, skin Mantoux test was strongly positive. manifestations serve as important A skin biopsy was consistent with the clues to systemic diseases. The diagnosis of papulonecrotic following are some illustrative cases. tuberculids. With anti-TB therapy all the lesions cleared. Tuberculids are Case 1 : A 14 year old girl considered to be a hypersensitivity complained of graying of hair since reaction to a hidden focus of 9 years of age. She also complained tuberculosis. of chronic weakness and fatigue. She was a vegetarian. Examination Case 4 : A 30 year-old man revealed dry, lusterless, brittle scalp complained of itchy black patches on hair. Approximately 30% of her hair his legs since 8 months and jaundice were gray. Her investigations with loss of weight since 2 months. revealed haemoglobin 12 g/dl and Examination revealed lichenoid vit. B12 60 pg/ml. Her final papules and plaques on both legs. diagnosis was premature graying Biopsy confirmed the diagnosis of with B12 deficiency. Her B12 lichen planus. Extensive erosive lichen planus can be a marker of deficiency was treated. Her Fig. 2 : HIV and Kaposi's sarcoma condition remains stable. hepatitis C infection. Serology for hepatitis C was positive. A final be positive for the HHV-8 virus. He Case 2 : A 17 year-old boy diagnosis of lichen planus with HCV subsequently developed pulmonary complained of patchy baldness. infection was made. and peritoneal effusions and died 3 (Fig. 1) He had generalised enlarged Case 5 : A 65 year-old menopausal months later of cardiopulmonary lymph nodes. Investigations revealed lady, complained of severe vulvar arrest. a VDRL of 1:16. He was diagnosed pruritus since 5 years. Examination Association of acanthosis nigricans as a case of secondary syphilis and revealed a pigmented scaly plaque on with insulin–resistant diabetes, treated with long-acting penicillin 2- her labia majora and minora. nodular vasculitis with pulmonary 4 mega units IM. His hair grew back Histopathology showed “extra- tuberculosis, Langerhan cell in 2 month’s time. mammary Paget’s disease”. A histiocytosis presenting as a vulvar vulvectomy was performed. The ulcer - the list of interesting skin patient has remained well since the clues to systemic diseases is endless. last 7 years. An astute dermatologist can often look beyond the skin to clinch a Case 6 : A 39 year-old married difficult diagnosis. heterosexual male presented with extensive purpuric macules, papules, and lichenoid plaques scattered over his skin and mucocutaneous surfaces since 1 year (Fig. 2). The lesions were Oil massage is good for an infant. larger in both his groins, and were Fact : This is true if the oil is Fig. 1 : Alopecia of secondary syphilis associated with lymphoedema of his non irritating e.g.olive oil, and the penis and scrotum. Serology for the Case 3 : A 43 year-old housewife massage is done gently by the mother HIV - 1 virus was positive. Biopsies complained of “boils” on her or the granny. Touch and a firm feel from multiple lesions confirmed the elbows since one year. Examination are more important than hard rubbing diagnosis of Kaposi’s sarcoma. In revealed small pea-size crusted which can irritate, damage, and view of the association of KS and papules on both arms (extensor produce boils. the HHV-8, his biopsy was subjected aspects). A tuberculid was suspected. to histochemistry and was found to VRM, NM

3 THE ADOLESCENT SKIN Dr. Nina Madnani

Adolescence is that phase in life when young. They also regulate the growth grease production. the beautiful, soft, smooth, cycle of the hair follicle to prolong childhood skin undergoes the growing phase. Rapid weight gain Dandruff : Dandruff is the excessive “horrific” changes due to the under the hormonal influence in a physiological scaling of the scalp. A effects of the newly produced genetically prone individual can result normal scalp liberates 487,000 cells/ 2 circulating hormones. The in unsightly stretch marks (striae). cm , a dandruff one sheds 800,000. androgens and the oestrogens are When associated with inflammation, mainly responsible for most of Several diseases can get modified the condition is known as these effects. The androgens during this period. Diseases like seborrhoeic dermatitis. Both stimulate the pilosebaceous tuberous sclerosis and conditions may be itchy. A yeast-like follicles to increase the production neurofibromatosis may increase organism is postulated in the of grease, and transform the hairs whilst icthyosis may improve. aetiology. Stress, heat and humidity can aggravate the process. from the original thin golden ones The commoner problems are to the dark pigmented ones. The Temporary relief is obtained by discussed below. skin becomes greasy (seborrhoeic), washing off the scales at frequent and prone to developing pimples. Greasy skin : This may be the first intervals using regular or medicated Dandruff and seborrhoeic sign of puberty. The skin assumes shampoos. Medicated shampoos dermatitis can start at this age. a thick oily appearance with usually contain one or a combination Excessive androgenic activity in a of the following, viz., zinc dilated pores of pilosebaceous female can result in a male pattern pyrithione, selenium sulfide, ducts, especially on the forehead, distribution of hair known as antifungals, salicylic acid, or tar. hirsuitism. Follicular infections nose, chin, and inner sides of the Usage requires a 5-10 min. contact increase because of a change in the cheeks. Mopping with an period before rinsing off. bacteria that inhabit the skin. The absorbent tissue or handkerchief, A minimum frequency of twice a sweat glands, the apocrine and frequent washing with special soaps week is required. Anti-dandruff eccrine glands, are also stimulated and washes, provide temporary shampoos do not cause graying of to increase their activity resulting relief. Dusting powders absorb hair or hair loss. Seborrhoeic in excessive sweating the grease and give a non-greasy dermatitis may require in addition (hyperhidrosis) and body odour. finish to the skin. In extreme topical steroid applications. Oestrogens work by counteracting cases anti–androgenic medication or the effects of the androgens. They Acne (pimples) : (Fig. 1) The onset of influence the blood supply and oral retinoids may be administered acne may be indicated by the skin thickness to keep the skin under supervision, to decrease the presence of a few blackheads (open

GUEST EDITORIAL (Contd.) Microscopic examination of small bits of skin tissue for better diagnosis and often as a treatment modality are additional facilities for patients in need of such services. Skin tissue or slides sent from other parts of our country or elsewhere are examined by dermatopathologists. This concept of dermatopathology as a separated relative of general pathology does not exist even in the majority of medical colleges and their associated hospitals.

Thus starting with only a magnifying hand lens in the footprints of Sherlock Holmes a limitless future is beginning to unfold itself for dermatologists and their patients. This issue of our newsletter is presented to highlight the various facets of this exciting speciality.

Dr. V.R. Mehta, Dr. Nina Madnani

4 excision/revision, etc. It may be the individuals are unaware of the almost impossible to get back a problem. Bacteria on the skin break flawless skin. down the sweat to liberate aromatic Stretch marks (striae) : These are products which smell bad. These unsightly dark pink to red skin – compounds get transferred to the coloured to white bands that can clothes and the odour can linger for occur on the shoulders, hips, days in unwashed clothes. thighs or back, in individuals who gain or lose weight rapidly. They Deodorants and antibacterial soaps indicate tears in the elastic tissue containing triclosan, and of the skin. The tendency to trichlocarban derivatives, or benzoyl develop stretch marks is peroxide, are effective in reducing the Fig. 1 : Adolescent acne genetically controlled. Application of bacteria but do not reduce the comedones ) or whiteheads (closed retinoids, glycolic acid preparations, sweating. Sweaty clothes should not chemical peels or the use of lasers comedones) on the face. As the be re-worn without washing. Use of may lighten but never completely get condition progresses, pustules and cotton clothes should be encouraged. nodules may develop. Genes and rid of the marks. Intracutaneous injections of botox hormones are the main causes. Oral Excessive sweating (hyperhidrosis): into the culprit areas are effective in corticosteroids and anabolic steroids Teenagers may experience excessive sweat suppression. found in certain body-building sweating of their palms, soles, and supplements, anti-tuberculosis underarms. This is aggravated during medications, etc. may precipitate or Infections : Summer can herald the periods of emotional stress, excessive aggravate acne. 80% of individuals onset of skin infections. Poor physical exertion, and in hot humid develop acne during their lifetime. hygiene, badly fitting clothes, obesity, weather. This becomes a source of Most are amenable to topical anti- excessive sweating can predispose to social embarrassment for the individual. acne agents like sulfur, salicylic acid, boils, abscesses and fungal infections. benzoyl peroxide, antibacterials, and Students may find writing examination Treatment with oral antibiotics and retinoids. The more inflammatory papers difficult. Anti-perspirants forms may require oral antibiotics, containing hexahydrated aluminium topical anti-bacterial creams is and those with a hormonal chloride in absolute ethanol are effective. Bathing with soap is imbalance, anti-androgenic agents. In effective in suppressing sweating in the encouraged after returning from severe cases, or relapsing cases, oral axilla, but fail on the palms and soles. schools/colleges or after strenuous Officinal tannin and formaldehyde isotretinoin for 4 to 6 months is physical activities. A change of preparations work better on these advised. Blood monitoring is clothes, especially underclothing, is mandatory. Pregnancy is cautioned sites. If these fail, tap water required. against whilst on the treatment. iontophoresis may be advised several times a week. In extreme cases, Facials which involve vigorous The teenager’s skin is continuously massage of the face, and acne endoscopic thoracic sympathectomy undergoing physiological changes. surgery by unqualified individuals is may be required. Recently, discouraged. Food has no role. Most injections of botulinum toxin Tensions between parents and of the adolescent acne tend to clear (Botox) into the skin of the axilla and children, peer pressure, academic by the age of 20. Untreated acne palms and soles have been successful stresses underlie conditions like acne that persists for several years can in suppressing sweating for 6 to 9 excoriate, dermatitis artefacta, lichen leave permanent scars. Early months. Side effects are minimal with simplex nuchae, trichotillomania, and treatment prevents this complication. good operator expertise. atopic dermatitis The adolescent Scars can be reduced with cosmetic and surgical treatments like Body odour (bromhidrosis): Excessive needs guidance and support to get microdermabrasion, surgical sweating is very often accompanied him/her through this emotionally dermabrasion, laser resurfacing, scar by body odour. Curiously, most of trying phase.

5 LABORATORY INVESTIGATIONS IN HIRSUTISM Dr. Vipla Puri Simple evaluation should include: • Testosterone, both free and total • Dehydroepiandrosterone sulphfate (DHEA-S) • Androstenedione A more extensive evaluation should include the following : • Follicle stimulating hormone (FSH) • Luteinizing hormone (LH) • Sex hormone binding globulin (if free testosterone is not available). • Dihydrotestosterone (DHT) • Oestradiol • Prolactin • Cortisol • Dexamethasone suppression test Simple testing can identify the cause in about half the patients with hirsutism, extensive evaluation may be required for the rest. In addition, these investigations can exclude any significant pathology. like androgen producing neoplasms, Cushing syndrome or congenital adrenal hyperplasia.

We are pleased to announce the start of a “Vulvar Clinic” at the P.D. Hinduja National Hospital & MRC. Over the years, we have diagnosed and successfully managed several unusual vulvar conditions like extra mammary Pagets disease, Langerhans cell histiocytosis, lichen planus, psoriasis, etc. As vulvar diseases are generally ignored /neglected, this clinic would be a boon for patients suffering from vulvar conditions like pruritus, pain, infections, ulcers, growths, etc. The patient will be seen by a dermatologist and a gynaecologist at the first visit. Investigations such as smears, biopsy, colposcopy, PAP smear will be performed if necessary. Detailed report will be sent back to the referring physician. The clinic will be run jointly by Dr. Nina Madnani (Dermatologist) and Dr. Ashwini Bhalerao Gandhi and Dr. Dulari Vora (Gynaecologists) on Mondays and Fridays between 5 pm and 6 pm at the P.D. Hinduja National Hospital & MRC, Mahim and on Saturdays between 5 pm and 6 pm at the Hinduja Satellite Clinic, Charni Road. This is the first “Vulvar Clinic” in India.

Oiling the hair makes it grow thicker and faster Fiction : Oil serves as a lubricant to detangle the hair. It conditions the hair giving it a luster. Oil cannot penetrate the scalp to reach the hair roots. Steaming the face opens up the pores and cleanses the skin. Fiction : Steaming the face actually causes swelling of the skin which reduces the pore size. This can sometimes aggravate the acne process. VRM, NM

6 FACIAL REJUVENATION SANS SURGERY Dr. Nina Madnani

Have you ever wondered where all the texture of the aged skin. Today, we should contain one or more of the those wrinkles have come from? Where have several tools which can following: alpha, beta, polyhydroxy has that beautiful baby skin gone? dramatically help a person look acids, tretinoin, vit. A/vit C and E, younger. superoxide dismutase, co-enzyme Q- The indisputable fact is that our skin 10, copper, green tea, and silimarin. starts aging from the day we are born. Cautious dietary supplementation of A lot of the above ingredients are antioxidants like vit. C, E, beta Aging is dependant on two factors- very unstable and require very special carotene, alpha-lipoic acid may have formulations to maintain their genetic and environment. Sun some rationale if used in the right stability. They need to reach deep into exposure, the main environmental quantities. the skin in specific concentrations in factor, is responsible for 90% of the order to be effective, and they Sunscreens form an important unwanted effects. The others are should be free from side effects. This component of every skin care environmental pollutants, smoking, requires very superior manufacturing regime. They block part or whole stress, excessive use of alcohol, and techniques and know-how. of the UV spectrum which is poor nutrition. Environmental wear responsible for skin damage. Each The alpha hydroxy acids, major and tear generates free radicals which sunscreen has a sun protective factor players in anti-aging, act on all damage and ultimately cause death of (SPF). This indicates how many more layers of the skin, resulting in a skin cells. Our body has a natural times an individual can stay in the sun smoother, more even, and softer protective mechanism to scavenge without getting burnt. If 1 hour skin. They can occasionally irritate these free radicals. It consists of exposure would have normally sensitive skins. The newer poly - hydroxy acids have the same vitamins C and E, glutathione, and caused skin redness, after using 10 SPF sunscreen, an individual can stay beneficial effect minus the cysteine. But often, the damage exceeds irritation. Alpha and beta hydroxy repair. The ultraviolet component of in the sun for 10 hours without developing a burn. Sunscreens may peels can be performed on aging the solar spectrum penetrates deep into and discoloured skins for a more protect against UVA, UVB or both. the dermis and damages the collagen rapid improvement. They are They may be chemical sunscreens performed every 3-4 weeks for a and elastic fibers. (These fibers give skin which are cosmetically acceptable or its smoothness and suppleness.) minimum of 6 sessions by a physical sunscreens which form a dermatologist. Person can Smoke too plays a major role in white opaque layer on the skin. In immediately go back to work after the aging process. It generates order to be effective, a sunscreen having a peel done. Although the matrix metalloproteinases (MMPs) should be applied at least 45 minutes skin does not visibly peel, which damage the collagen and elastic before going out into the sun. It regeneration of skin occurs at the tissue. should be reapplied after 2 hours microscopic level, giving the skin and more often if exposed to water a glowing fresh look. If carelessly An aging skin displays one or more of or whilst sweating. Swimming performed, skin irritation, burns, the following: wrinkles, pigmentation, requires the use of water–resistant pigmentary changes and scarring freckles, lentigenes, depigmented spots, sunscreens. Regular use of can occur. Operator expertise is loss of tone and elasticity, increased sunscreens can partially reverse the essential. Trichloracetic acid and tendency to bruising, skin tags, degenerative changes in the skin. phenol peels in specific keratoses and telangiectasias. Initially, Sometimes, sunscreen ingredients concentrations are deeper peeling can cause photoallergic reactions agents and require extra caution the signs may be very subtle, but over and would need to be when performed, to prevent post the years, deepen, to the sagging, dull, discontinued. peel complications. yellowish, thick skin with deep wrinkles. These changes are more evident on the The market is flooded with various Tretinoin is the only FDA approved agent for anti-aging. It inhibits the sun-exposed areas. “magic potions” which promise a younger skin in 6 weeks. Don’t be effects of the damaging MMPs and Face lifts have been available since fooled. Products which can reverses the photoaging changes. Not decades, but a face lift does not change actually make a difference to skin only does it improve the collagen

7 and elastic tissue, but it also improves effects are seen only after several and the excimer laser systems are the dyschromasias and results in a weeks of usage. efficient for resurfacing, whilst the younger, more supple skin. It can Hydroquinone 2% - 8% is a Nd-YAG and intense pulse light increase the tendency to prescription lightening agent, which systems are suitable for remodelling photosensitivity, and the patient is combined with the anti - aging the dermis. should be advised to use sunscreens regimes to give a clearer Once deep wrinkles have formed, regularly. Another retinoid, retinol, complexion. Irritation can be an other procedures like injections of when applied to the skin, is unwanted side effect necessitating botulinum toxin (Botox), and fillers converted in the skin to its active discontinuation. Long-term use may for tissue augmentation can be form, the aldehyde. Although sometimes increase the pigmentation. performed to obtain a wrinkle-free cosmetic companies use it in almost look. homeopathic concentrations, Superficial cryotherapy has shown good scientific studies have shown results in facial resurfacing in type 1 Injections of Botox into the muscles its effectiveness in reversing to 3 skins. There is a greater chance of expression of the face and neck the aging changes. A of post procedure dyspigmentation cause temporary muscle weakness minimum concentration is required in the darker skin types. lasting for periods of 3 to 6 months. for efficacy. Microdermabrasion is a procedure The muscles causing the frown lines which can be used for very early on the forehead (Fig. 1), sides of the For Vit. C to be effective in creams, photoaging changes, especially when eyes are commonly targeted. Newer it should be available as a 20% the patients do not want to undergo indications for Botox include formulation as L-ascorbic acid. It neutralizes the free radicals, protects against UV damage, stimulates collagen growth, and regenerates vit. E and other antioxidants. Vit. E acts like vit. C and their combination is synergistic in UV protection. It also prevents the immunosuppressive effects of UV light. Vit. E gets rapidly oxidized to its inactive state. Hence stringent manufacturing Fig. 1: Pre and post botox treatment requirements are needed for it to be effective. It is effective only as alpha surgery. In this procedure, aluminium changing the shape of eyebrows, tocopherol. oxide or salt crystals are blasted onto flattening of the upper parts of the the skin and sucked back into the naso-labial folds, poppley chin, The aging skin suffers from machine together with the abraded softening a square jaw, lifting the pigmentary alterations. Freckles, skin cells. The result is a smoother angles of the mouth, for smoker’s nevi, lentigenes increase over time. glossier skin. Multiple sessions are lips, neck lines and folds. When Patchy areas of pigmentation and required. Reports also claim a performed by a trained physician, depigmentation mar the clear remoulding of the dermal tissue results are dramatic, and side effects appearance. Certain topical skin after several sittings secondary to the minimal. Facial rejuvenation never lighteners are added to skin creams inflammatory changes produced by was so simple. Side effects include with the aim of reversing/reducing this procedure. bruising, local pain and stinging, these changes. These creams swelling, and rarely, lid ptosis. These contain sunscreens, kojic acid, Laser systems have been used to effects are temporary. The arbutin, etc. These agents act as resurface the epidermis or remould maximum effect is seen after 5 to 10 antioxidants, and skin lighteners. The the dermis. The CO2, Erbium-YAG days. The dosage varies according to

8 the bulk and the action of the muscle more than 40 synthetic fillers frown lines, naso-labial folds, and to be injected. “Top-up” injections available. The fillers are usually into the lip or cheeks for can be performed if required after injected /implanted into the mid/ augmentation. When large areas have 3 weeks to obtain the required deep dermis. They remain there and to be filled, fat can be removed effect. It’s use is contraindicated in slowly get absorbed or incorporated from one part of the body and patients with neuromuscular into the normal tissue. Some of the injected into the required area. Again disorders. earlier fillers were made from operater expertise and technique bovine or porcine collagen. The determines the final result. Various fillers have been devised to newer ones are human-derived and replace or augment the loss of contain hyaluronic acid. These have less Our advice for a perfect skin - eat dermal tissue which takes place with chances of an allergic reaction and healthy, avoid stress, avoid the sun, aging. The earliest filler used was do not require prior patch testing. sleep on your back and of course, one’s own fat. To date there are These fillers are injected into the skin choose your parents carefully !

DIET AND SKIN Dr. Rajeev Joshi

We are what we eat. Nowhere is this transepidermal water loss. Resulting Dermital : The allergy is to protein. adage more relevant than in the skin. changes lead to pruritus and dermatitis. It is either of the immediate Dietary deficiences and excesses hypersensitivity type mediated by Dietary excess manifest as specific dermatoses. IgE antibodies (urticaria), or a Dietary excesses are common in our Dietary deficiencies delayed hypersensitivity mediated by modern urban society with easy T lymphocytes (protein contact Deficiencies of vitamins B complex access to rich fatty food, a sedentary dermatitis). Mixed reaction with and vitamin A and vitamin C lead to lifestyle, and lack of physical both IgE and lymphocytic mucosal and cutaneous changes. exercise. Obesity leads to insulin involvement occurs in atopic Glossitis and cheilitis and pellagra are resistance with secondary acanthosis dermatitis. Egg albumin, sea foods common presentations of vitamin B nigricans (dark, brown-black, velvety like prawns and other shell fish, and skin prominently in flexures like the complex deficiency especially of legumes and nuts are commonly axillae, cubital fossae, the groins, and thiamine, riboflavine and niacin. associated with allergy. Preservatives the sides of the neck). Obesity leads Conjunctival xerosis and Bitot’s spots and colouring agents can lead to to intertrigo (inflammation of are associated with vitamin A allergic reactions. Chemicals like deficiency. Lack of vitamin C leads to apposed skin of body folds) with tartrazine, cinnamic aldehydes and scurvy with swollen bleeding gums and secondary fungal and bacterial benzoic acid are often incriminated skin haemorrhages. Acute zinc infections. Benign pigmentation of in urticaria. Preserved foods like deficiency leads to erosive periorificial skin occurs in carotenaemia and pickles, jams, etc. are best avoided dermatitis (acrodermatitis lycopenaemia due to excess ingestion by persons suffering from chronic enteropathica), while long standing of beta carotene (carrots) and unexplained urticaria. Food allergy in chronic zinc deficiency leads to lycopene (tomatoes). atopics develops in early childhood, psoriasiform changes of the skin. Disease causation Essential fatty acid deficiency, due to usually before 2 years of age. Allergy food faddism or in genetic diseases Allergy to various food items is to cow’s milk is not uncommon and leads to atopic dermatitis and dry implicated in dermatological switching over to soya bean-based xerotic skin with impaired epidermal conditions like urticaria, atopic products is often helpful. Food barrier function leading to increased dermatitis and protein contact. allergy often manifests within few

9 minutes to few hours of ingestion by ingestion of certain foods. are myths without any scientific data of the offending food item and may Dermatitis herpetiformis is often to support them: present with acute urticaria, associated with gluten sensitive • Exacerbation of acne by angioedema and crampy abdominal enteropathy. Gluten is a protein chocolates and oily foods pain with diarrhoea. Atopics, on found in wheat. Avoidance of wheat- • Fish and milk and milk eating foods they are allergic to, containing food products like products causing vitiligo develop sudden flares of their chappatis, bread and biscuits helps • Non-vegetarian food being dermatitis with attacks of in reducing the intensity and extent bad for the skin paroxysmal itching. of both the enteropathy as well as the skin eruptions. Iodine can In sum, our diet affects our skin Food allergy testing is done by skin exacerbate acne and cause erythema and a well balanced, nutritious diet prick test. It detects immediate type nodosum. Avoidance of iodized salt, coupled with a healthy regular of hypersensitivity and is advisable iodine-containing multivitamins and lifestyle goes a long way towards in patients who have a strong cough syrups may be necessary in healthy skin. Eating natural foods, temporal association of symptoms these individuals. fruits and vegetables along with after ingestion of suspected foods. plenty of water is the best recipe Myths Food allergy apart, some skin for the fresh, glowing look that diseases are known to be exacerbated Several myths abound. The following we all desire.

DRY SKIN Dr. Rajeev Joshi

Dry skin (xerosis) is a well known environmental irritants and allergens, impaired barrier function of the skin. and prominent feature of several leading to atopic eczema. The skin normally functions as a skin disorders, both genetic and semi-permeable membrane allowing Dry skin is common in the elderly acquired. water and electrolytes to pass to the who have reduced sebum secretion outside, while restricting the entry of and age-related thinning and atrophy The group of ‘ichthyoses’ are inherited noxious chemicals and pollutants of their skin. skin diseases, characterized by the from the external environment. This presence of large fish-like scales that The incidence of atopy (both allergic skin barrier is located primarily in the are present since birth or appear in early asthma and skin eczema) has shown upper part of the epidermis. childhood. Ichthyosis vulgaris, the most an alarming increase in the last few Integrity of this barrier function is common and the least severe of the decades, coinciding with our shift to due to the physical toughness of the ichthyoses’ has an autosomal dominant a modern urban environment. In non-living keratin of the stratum mode of transmission and presents certain areas of the western world corneum and the extracellular lipid with generalized dry skin and polygonal atopy affects almost 1/3rd of the content of upper epidermis that is brown-black scales mainly on the legs population, especially the paediatric formed by the intercellular lipid and forearms. More widespread population. In India too the deposition. involvement is rare. Patients tend to incidence of atopy and atopic Disruption of this barrier occurs worsen during winters due to decreased dermatitis is on the rise, especially in cities and in the high socio-economic either due to external physical ambient humidity. strata. damage (cold dry weather, Atopic dermatitis is associated with detergents, chemicals, microtrauma, Pathogenesis generalized dry skin that leads to etc.) or due to inherent decrease of severe, intolerable itching and an Dry skin occurs due to increased or abnormality of the epidermal increased sensitivity of the skin to transepidermal water loss because of lipid layer.

10 Atopy and its associated tendency to eczema / occupational Use of cotton gloves dry skin is an important predisposing eczema) due to contact with underneath waterproof factor for the increase in eczematous soaps, detergents, and gloves is helpful in wet work skin disease. Airconditioning leads to chemicals (B) Use of emollients and prolonged exposure to low humidity, iii) Asteatotic eczema of the moisturizing agents aggravating the preexisting tendency extremities and back in the for dry skin. Emollients are the first-line of elderly (many geriatric treatment for dry skin and eczema Nutritional deficiences of trace patients develop this in arising due to dry skin. They are elements like zinc and especially of hospital due to prolonged effective moisturizers that help to the essential fatty acids (linoleic stay in the centrally air keep the skin moist and flexible and linolenic acids) secondary to conditioned surroundings) and prevent cracking, flaking and bowel disease, food fadism or itching. iv) Facial dermatoses due to abnormal metabolism of fatty acids irritant and allergic Emollients come in different (atopic dermatitis) lead to reactions to cosmetics and forms, i.e. ointments (water in oil), deranged epidermal barrier environmental pollutants. creams (oil in water), lotions and function and dry skin. bath oils. All serve to restore the All these conditions are quite moisture in the epidermis of the Clinical features common and are distressing to the skin and give the skin its natural patient as they persist for long and Dry skin manifests with a variety elasticity. of presentations, many of which interfere with their daily lives. are not recognized as being due to Their effective management Ointments and thick creams are dry skin. underscores the need to appreciate more suitable for dry and thick skin and understand the underlying and for bedtime use. Creams are All of us experience some degree problem of dry skin. cosmetically more acceptable than of chapping of lips and dry the ointments but need to be used Tips on how to manage dry skin irritable skin over the extremities more often and are suitable for the during winter. This is due to the (A) Preventing excessive dryness of face and intertriginous areas. decreased ambient humidity that skin Lotions are cool and soothing and reduces the epidermal moisture • Avoid multiple baths best suited for application to large content, leading to flaking and areas during the day. scaling of the stratum corneum. • Use lukewarm water for bathing Regulation of an optimal moisture Bath oils hydrate the entire skin content is very important, as too • Avoid use of harsh soaps uniformly by causing a fine film much moisture leads to soddening and deodorent soaps of oil on the skin which traps of the skin while too little • Avoid harsh towelling to dry water and keeps the skin soft and moisture leads to dry scaly skin. the skin, instead gently pat flexible and prevents cracking. In most individuals this is dry after bath A daily schedule of skin care for asymptomatic except for mild • Avoid use of woollen persons with dry skin would consist irritation of the affected areas. It clothes. Loose cotton clothes of is easily controlled by the use of are preferable appropriate moisturing agents. • Humidify the atmosphere in • Bath oil with the morning bath However, in an increasing number winters or if regularly using of people dry skin is a problem. airconditioning • Use of moisturizing cream Clinical entities due to dry skin are: • For persons with dry skin of immediately after the hands avoid prolonged bath. (within 5 minutes of i) Atopic cheilitis contact with water, patting the skin dry) ii) Hand eczema (housewife’s detergents and chemicals.

11 • Use of moisturizing cream Choice of emollients is important Perfumed products are best avoided or lotion during the day to and is very individual. The best is a and frequent changes of products is special sites that need trial and error method to select the not advisable. Once a product is attention (hands, face, etc.) products that are suitable and agree found suitable it is best to use it on • Use of a heavy cream or with the person’s skin. a regular basis. ointment at bedtime

FACIAL PIGMENTATION Dr. Rajeev Joshi

Facial pigmentation is a common with any specific disease. It is due to • HIV infection reason for a dermatological increased melanin in the periocular skin • Debilitating diseases (e.g. consultation. Today, with hightened due, both to physical and emotional miliary TB) level of cosmetic awareness, small stress. Hormonal changes, eye strain blemishes of the skin, especially on the and sleep deprivation are contributing Melasma or chloasma (mask of face are perceived as social disasters, factors. Allergic contact dermatitis of pregnancy) is the most common facial leading to severe psychological the eyelids and atopic dermatitis are pigmentary disorder. It is not restricted morbidity. other causes of darkening of to pregnancy but is seen in both sexes periocular skin. Facial pigmentary changes (fig. 1) and appears to have a familial tendency. present with a variety of clinical Conditions causing facial pigmentation Hormonal changes and ultraviolet presentations, some being well defined (UV) radiation from sunlight are the Well defined clinico-pathological main factors causing this condition. The clinico-pathological entities while entities others are related mainly to a malar region, the middle of the nose combination of stress and unhealthy • Melasma (chloasma) and the forehead are most commonly lifestyles. Allergic reactions are more involved. The chin and upper lips are • Berloque dermatitis common on the thin and sensitive facial affected in a smaller percentage of skin. Sun exposure is a major factor in • Poikiloderma of Civatte cases. Melasma is almost always bilateral and symmetrical in appearance. perpetuating these conditions and • Toxic melanosis protection of the face from the In classical melasma (epidermal type) deleterious effects of UV radiation is • Riehl’s melanosis increased melanin is restricted to the basal layer of the epidermis, appears a very difficult task. • Pigmented contact dermatitis brown in colour and is accentuated if Dark circles around the eyes is a Other conditions causing facial viewed through the Wood’s lamp. common complaint not associated pigmentation Darker shades of brown and slate gray pigmentation are seen in the mixed and • Localized pigmentation dermal varieties of melasma where the • Post inflammatory pigment is deposited in the upper pigmentation dermis and is more difficult to treat. • Lichen planus Berloque dermatitis was very common in • Discoid lupus erythematosus the early part of the last century and presented with streaky pigmentation of • Diffuse pigmentation the face and sides of the neck that was • Addisons’disease asymmetrical and occurred due to a phototoxic reaction and subsequent • Haemochromatosis pigmentation due to oil of Bergamot Fig. 1 : Facial pigmentation • Vit B 12 deficiency used in earlier cosmetics. Oil of

12 Bergamot contains coumarins which dermis. Photoallergic or phototoxic cosmetic acceptability, and the cause photosensitivity. reaction to various chemicals and possibility of developing allergic fragrances commonly used in sensitivity to their ingredients. Physical Similar streaky pigmentation may be cosmetics, toileteries and washing methods of sunprotection like use of seen following exposure to naturally agents cause this melanosis. protective clothing and use of caps and occurring coumarins in citrus fruits and umbrellas are very useful and cheap raw mangoes. This type of Pigmented contact dermatitis is alternatives to the commercially pigmentation is often seen in children photoallergic reaction leading to available sunscreens. and occurs around the mouth with pigmentation and is synonymous with linear streaks, as well as on the dorsae Riehl’s melanosis and toxic tar Medical treatment of facial melanosis, of fingers and the adjacent web spaces melanosis. Chemicals commonly especially melasma, consists of use of due to contact with citrus fruit juice or implicated in pigmented contact bleaching agents like hydroquinone mangoes and subsequent sun exposure. dermatitis include optical whiteners (2-4%). Hydroquinone itself can lead used in washing powders, azo dyes to phototoxic reactions and worsening Poikiloderma of Civatte is reticular used in textile industry, cosmetics of the pigmentation. Its use should be pigmentation that is seen in the elderly containing fragrances like jasmine, immediately discontinued if any due to chronic sun damage of the facial lemon oil, citronella and benzyl redness or burning occurs after its use. skin. The pigmentation is accompanied salicylates, colours like brilliant lake red by mottling due to telangiectases and It should preferably be used at night R, and bactericides like carbanilides. before going to sleep to minimize small reddish or bronze coloured Carbanilide was an ingredient of the possibility of a phototoxic reaction. macules intermingled with white popular Lifebuoy soap and was atrophic spots. implicated in numerous cases of Mild low-potency topical steroids are photoallergic dermatitis and Toxic melanosis (tar melanosis) is a also used in addition to hydroquinone photomelanosis. Carbanilides are no phototoxic melanosis that was and addition of a topical retinoic acid longer used in the toiletry industry. originally described in tar handlers, and (Kligman’s formula) gives faster results with less side effects. Other agents like is due to photoreaction of Pigmented contact dermatitis is more kojic acid and glycolic acids are used hydrocarbons present in tar. The severe in people with dark skins as in as facial peels. eruption consists of small coalescing them the pigmentation is deeper and pigmented macules on the face, trunk more intense with a smaller In pigmented contact dermatitis patch and extremities reflecting contact with eczematous reaction. tests and phototests of suspected the photoactive chemical. Because sun exposure is a very chemicals and products are advisable Riehl’s melanosis is characterized by important factor in the pathogenesis of and strict avoidance of the incriminated spotty, dark, brown-black these facial melanosis, strict chemical is necessary. Use of short pigmentation that is most intense on photoprotection is essential for their courses of oral steroids is often the forehead, preauricular, and management. UV radiation, especially beneficial in extensive pigmented mandibular regions and sides of the long-wave UVA, penetrates window contact dermatitis. Long-term neck. It is a photosensitivity dermatitis glass and use of a sunscreen is prognosis however is guarded as strict that begins with erythema and pruritus mandatory even when indoors. photoprotection and avoidance of leaving behind dark pigmentation due Practical problems in the use of allergic chemicals is often not possible to deposits of melanin in the upper sunscreens include the high cost, poor over an extended period of time.

Dr. C.V.Vanjani conducted a workshop on “Vascular Color Doppler” on behalf of the Asian Educational Committee, in Karachi, Pakistan from 17-19 January, 2004. This was attended by 285 delegates from all regions of Pakistan.

13 SORE MOUTH Dr. Rajeev Joshi

The oral cavity is a no-man’s land, atrophic glossitis and a characteristic Recurrent aphthous ulceration is a serving as an interface for the magenta-coloured tongue. Response common, recurrent, painful diseae interaction of various specialities, to 5 mg of riboflavin daily is of the oral mucous membranes that viz, dentistry, ENT, dermatology, dramatic. Thiamine (B1) deficiency begins as small discrete or grouped and internal medicine. causes a red, burning tongue. papules or vesicles that rapidly Cyanocobalamin (B12) deficiency become necrotic and ulcerate. Several cutaneous diseases manifest leads to glossitis with bright red Typical aphthae are 3-5 mm round with oral lesions that may be tongue. Glossitis and cheilitis are shallow ulcers with a white or restricted to the mouth or may be also seen in folic acid deficiency. yellow floor surrounded by a ring the presenting feature of systemic In pellagra (deficiency of niacin) of erythema. They are exquisitely diseases. the skin manifestations are painful and interfere with speech A ‘sore mouth’ may lead to diagnostic but mucous membrane and eating. They typically last for profound morbidity due to the involvement is also seen with two or three weeks, whereafter severe pain and discomfort that the glossitis and painful fissures and they spontaneously heal. The patient experiences and also ulceration of mucous membranes. buccal and labial mucosa and the because it interferes with normal sides of the tongue are most Vitamin C deficiency leads to nutrition. commonly affected but palate and haemorrhagic gingivitis with other areas of the mouth may also Many patients with sore mouth are swollen, bleeding gums. be involved. unaware that their problems are Treatment of all these conditions primary skin conditions, best Episodes of aphthae tend to recur is replacement of the deficient treated by a dermatologist. at variable intervals and vitamin. Most often, however, recurrences are often induced by Common conditions associated multiple vitamins are deficient and minor trauma due to a toothbrush with a sore mouth are: apart from replenishing vitamins, or biting of the cheeks. Emotional advice regarding balanced • Nutritional deficiencies stress and periods of hormonal nutrition and change in lifestyle is changes like menstruation or • Tobacco-related stomatitis necessary. menopause are known triggering • Recurrent aphthous stomatitis Tobacco-related stomatitis iscauses. • Oral candidiasis common in our country, due to • Erosive lichen planus Recurrent aphthosis can be a very chewing tobacco in various forms distressing and frustrating • Stomatitis due to autoimmune [paan, ghutka, plain tobacco with condition as it may continue for bullous diseases lime and even use of tobacco years and there is no known cure. Dental problems associated with (masheri) for cleaning teeth]. Alleviation of the acute pain may sore mouth will not be considered Long-term tobacco use may lead to be achieved by topical xylocaine or here. submucous fibrosis where there is topical steroids in special orabase Nutritional deficiencies, especially progressive fibrosis of the of the B group of vitamins, lead submucous tissue of the oral mucosa, to stomatitis and are most often leading to a hard pale mucosa with seen in chronic alcoholics, food progressive inability to open the faddists, patients with debilitating mouth. Prolonged contact with diseases and patients on long-term tobacco can lead to the precancerous antibiotics. conditions of leucoplakia and erythroplakia and even invasive Riboflavin (vit B6) deficiency leads squamous cell carcinoma. A severe to the oro-oculo-genital syndrome painful stomatitis may also result in which the oral manifestations from the cumulative irritant effect of include angular stomatitis, tobacco use. Fig. 1 : Aphthous oral ulcer

14 formulations. Gargles of Oral candidiasis most commonly Less common causes of ‘sore mouth’ tetracyclines and betamethasone presents as ‘thrush’ where there is a include erosive lichen planus and oral are useful in some cases. Other whitish flaky pseudomembrane on the involvement in autoimmune bullous drugs like colchicine and topical erythematous mucus membrane diseases like pemphigus, cicatricial tacrolimus have variable efficacy. which can be rubbed off. Other pemphigoid and the recently described distinctive clinical forms of oral condition paraneoplastic pemphigus. The diagnosis of oral aphthosis is candidiasis include denture sore Pemphigus may remain localized to the usually easy and is made clinically. mouth, candidal glossitis, candidal oral mucosa without any cutaneous Atypical cases must be leucoplakia, atrophic glossitis, chronic involvement for several months and differentiated from other mucocutaneous candidiasis and therefore the diagnosis of these conditions, like Behcet’s syndrome angular cheilitis or perleche. conditions is often delayed. Mucosal (oro-genital ulcers), recurrent Treatment with oral fluconazole and biopsies with immunofluorescence herpes simplex infection, erythema topical clotrimazole gives good relief. studies is essential for correct diagnosis. multiforme and fixed drug Underlying predisposing causes for Treatment with high-dose steroid and eruptions. In all these conditions recurrent oral candidiasis like HIV other immunosuppressives like the ulcers are larger, irregular in infection, diabetes and other causes azathioprine or cyclophosphamide outline and last longer, for even of immunosuppression should be is necessary for control of these weeks, and may be haemorrhagic. ruled out. autoimmune diseases.

LEPROSY Dr. V. R. Mehta

Leprosy, caused by Mycobacterium TT reactivated spontaneous healing may leprae, a rod shaped bacterium, is D occur. Once the diagnosis is made a systemic human disease, despite T treatment becomes mandatory. For a its dominant effects on the skin single lesion one dose of rifampicin and nerves. An encounter with the Indeterminate 600 mg, ofloxacin 400 mg and SH BB bacterium is inevitable in crowded Leprosy minocycline 100 mg is advised. This environment. The outcome depends can be given as a monthly pulse, in case on the body’s reaction to the invader. of larger number of lesions, for 6 LL months. This responsibility lies with the lymphocytes, i.e. cell-mediated Fig1. Fate of indeterminate leprosy. If the infection succeeds in establishing immunity (CMI). The monocyte TT- Tuberculoid leprosy itself despite a good CMI, a localized (known in tissues as the histiocyte BB- Borderline leprosy type of disease develops. It is or macrophage) is closely associated LL- Lepromatous leprosy characterized by loss of sensation over a with CMI. The most favourable SH- Spontaneous Healing well-defined area of hypopigmentation outcome is destruction of the TD- Tissue Destructions with elevated borders (fig. 2) and a bacteria and the development of The diagnosis at this stage is often in depressed centre. The latter, in addition, immunity. If there is a hiatus in the doubt, the skin histopathology is often shows loss of hair and sweating, hence CMI, the bacteria multiply in the skin not helpful and the number of bacteria is scaly. A thick tender nerve is usually and a hypopigmented (whitish) or an too small to be detected even with present around the lesion. This erythematous (reddish) macular specific staining techniques. In this localization (containment of the patch that may or may not show situation polymerase chain reaction infection) is the result of T helper reduction in sensation, develops. This (PCR) can be used to detect bacterial lymphocytes (CD4+) which secrete is called indeterminate leprosy (fig.1). DNA or RNA. If the CMI becomes interleukin 2. IL-2 attracts cells like

15 natural killer (NK) and CD8+ cells. called LL the primary leproma and All of them lead to the production the simulator the secondary leproma. of interferon-gamma that stimulates The lesion of borderline leprosy bacterial destruction by the (BB) is a superimposition of macrophages. This is the classical tuberculoid on to that of Th1 response. Seen under the Fig. 3 : Nodule of lepromatous lepromatous producing a saucer microscope the disease simulates leprosy shaped lesion. ( Fig. 5). tuberculosis, hence is called tuberculoid leprosy (TT in fig. 1).

Fig. 4: Plaque of lepromatous leprosy Fig. 5: Saucer shaped lesion of Erythematous macules or dome borderline leprosy Fig. 2 : Lesion of tuberculoid leprosy shaped plaques with sloping edges The tuberculoid lesion may heal (Fig. 4) are often seen. Later stages The mononeuritis of leprosy usually spontaneously with ulceration due to are accompanied by bone develops as a gradually progressive cell-mediated immune response. The destruction, especially of the face, phenomenon. It is characterized by end result is an anaesthetic scar. feet and hands. Large nerve trunks tingling, numbness and weakness of Nerve damage causes paralysis of such as the ulnar and lateral popliteal muscles in the area of nerve muscles. Healing thus is at the cost are thickened but soft. The defense supply.Accidental injury to such a of body parts. Proper individualized depends on CD8+ T lymphocytes nerve, produces pain in its sensory treatment prevents such loss. A and involves antibody production distribution. Rapid progression variation consists of melanin that leads to hypersensitivity suggests either aggressive therapy of pigmentation instead of reactions, vascular damage and the disease or change in the immune hypopigmentation. With treatment autoimmune phenomena, e.g. status. the colour changes till a normal state thyroiditis and cryoglobulinaemia. Leprosy can simulate the so called is reached (Lepra tuberculoides et. All these correlate with a Th2 type saturday night palsy. pigmentosus de Mehta). response. At the other extreme is the Abnormal presentations include In fig. 1 between the two polar types manifestation of near absence of isolated lepromatous (LL) nodules in TT and LL, a mid borderline disease CMI. This allows bacteria to multiply the skin, muscles and other organs. BB is present. It may arise from the and cause generalized disease. Onset Association of leprosy with systemic with facial erythema may temporarily indeterminate type or from repeated diseases like diabetes mellitus, improve a fair lady’s appearance. A inflammatory reactions in hypertension and others is possibly constant cold or loss of eyebrows tuberculoid leprosy. The unstable the result of longevity. state is the result of other infections, and succulent shiny fingers may Recent developments accompany or follow the stress such as pregnancy, irregular presentation. Later the skin assumes treatment, but most often due to Though PCR for early diagnosis is an ertythematous orange peel wrong combination of drugs. If it an excellent addition to routine appearance especially on the face. progresses beyond the mid investigations, ELISA for phenolic Symmetrical nodules develop on the borderline state, a picture simulating glycolipid (PGL) antibodies is still of ears and elsewhere (fig. 3). LL evolves. Dr.V.R. Khanolakar limited use.

16 Table : Treatment regimes advocated by WHO for leprosy. MDT as practised today A 68-year-old male was diagnosed as is ideal for field work. having BT in reaction, with extensive lesions, oedema of the upper and lower Group Drugs Adult Children Children Regimen Duration (mg) (6-14yrs) (0-5yrs) extremities and neural involvement of (mg) (mg) both hands and feet. In addition he had diabetes mellitus and cirrhosis of the liver. PB Rifampicin 600 450 300 Once monthly 6, monthly The treatment of choice was ofloxacin supervised pulses to 200 mg and doxycycline 100 mg twice a DDS 100 50 25 Daily self - maximum day with 15 mg of prednisolone every administered 9 months morning, reduced gradually and stopped over a period of 6 months. All skin MB Rifampicin 600 450 300 Once 12, lesions healed and (surprisingly) all neural monthly monthly changes recovered a great deal. This Clofazimine 300 150 100 supervised pulses to patient would have been in a quandary Dapsone 100 50 25 Daily self - maximum in the sixties, with dapsone montherapy Clofazimine 50 50 (AD) 50 (TW) administered 18 months or later with rifampicin, both being PB: paucibacillary. MB: multibacillary AD : alternate day TW : thrice weekly hepatotoxic.

Tetracycline, ofloxacin and related cheek and the ear were involved over a Soaps should not be used on dry skins compounds sultamicillin and fusidic acid period of 2 years. In 1999 both the drugs all given orally can be combined in were replaced with 20 mg of Fiction : All types of skins need to be different formulations with dapsone for prednisolone every morning and 100 mg cleansed of pollutants, dirt, grime, and individualization of therapy. of clofazimine thrice a day. The reaction bacteria. Special syndet soaps and soap free cleansers which are gentler on the subsided, but he developed bronchitis. Acceptance of corticosteroids in skin have been formulated for dry skins. management has been the greatest The pulmonologist stopped the Psoriasis, eczema, vitiligo are advance in the last 30 years. prednisolone and the lesions reacted again. During a period free from treatable conditions. The future lies in early diagnosis, possibly bronchitis, dapsone 100 mg once a day Fiction : Fact Pimples are caused by use of vaccines and shorter therapy. The was reintroduced and well tolerated. He “heat” in the body. world had 12 million active leprosy continued to do well with prednisolone patients in the eighties and now the Pimples are caused by a combination at 15 mg, dapsone 100 mg, and number is 2.5 million. of genes and hormones. clofazimine 100 mg thrice a day, except Unusual presentations Shampoo causes hair to turn grey during episodes of bronchitis when and fall out. A 60-year-old patient developed a prednisolone was stopped. Sultamicillin borderline tuberculoid plaque on the 1 tablet twice a day could not be sustained Fiction : Shampoos are specially cheek in 1997. He was treated with beyond a month because of the high formulated to cleanse the scalp, just as a soap is used to cleanse the skin. dapsone 100 mg a day and rifampicin cost. Rifampicin 600 mg a day was added Keeping your scalp clean by regular 600 mg a day. The lesion became and prednisolone reduced gradually and shampooing will help in reducing scalp oedematous and scaly. The treatment was stopped. All symptoms including the scaling and infections. stopped. He was treated with the same bronchitis cleared up and he was combination intermittently, till the whole continued on dapsone monotherapy. VRM, NM

Dr. (Mrs.) Phulrenu Chauhan Consultant Endocrinologist, attached to P.D. Hinduja National Hospital has started a specialised clinic on “Paediatric & Adolescent Endocrinology”. The Clinic will be conducted every saturday from 10.00 am to 12.30 pm.

17 WATCH THAT BIRTH MARK Dr. V. R. Mehta

Birth marks usually result from Indications for removal of increase in the small blood vessels. intrauterine events and are called pigmented nevi are If the eyelid is involved, possibility “mother’s mark”, meaning a nevus. of similar changes inside the eye and • All giant nevi ( 20 cm in They are not caused by changes glaucoma (increased eye tension) diameter) because of their in the external environment. should be suspected. Therefore an malignant potential They may show only colour changes ophthalmologist’s opinion is and may be elevated or depressed • Persistent itching, tingling and necessary. The meninges on the same in relation to the skin surface. burning in the nevus side as the nevus may be involved in Almost everyone has a nevus. • Change in colour resulting in a this disorder. The earliest Some have many of the same mixture of black, yellow, manifestation of this is epilepsy kind and others exhibit brown, white and red (play of followed sequentially by brain different types of nevi. Each variety colours) atrophy and paralysis of the needs observation for a different opposite side of the body. A reason. • Spontaneous hair loss. Change in hair colour from black to white simultaneous increase in Pigmented nevi comprise melanocytes melanocytes results in extra • Gradual increase in size with melanin in the tissues causing or cells related to them, called nevic development of irregular melanocytes (nevus cells). acceleration in disease progression. borders, change in texture and Various MRI techniques are The common mole is a pigmented development of new pigmented available for early detection in nevus that may be present at birth, nevi or similar spots around it infants born with this nevus. or may develop later and then • Halo around the nevus with Extensive facial haemangiomas belong to the group of acquired jagged edges (nevi) may be associated with nevi. Sun exposure, UV light, coarctation of the aorta, a variety with or without psoralens, • Darkening of other moles in the of skeletal abnormalities and brain exfoliative dermatitis, viral absence of pregnancy and tumours. Bleeding caused by exanthems, HIV infection and alkaptonuria sequestration of platelets into the incompletely defined pollutants • Doubtfully enlarging nevus nevic vasculature is more likely may precipitate them. Great causing pigmentation of during a surgical procedure than personal and often astrological exposed skin sites. Patients otherwise. significance is attached to usually come for the pigmented nevi. People take great pigmentation Familial collagenomas represent nevi pains to preserve the auspicious with excessive collagen and reduced ones, e.g., a brown tulsi-leaf Dysplastic, atypical nevi, tend to elastic fibres.The shagreen patch like lesion on the subclavicular behave differently from those (firm plaque) of tuberous sclerosis described above, despite an region, congenital melanocytic belongs to this category. Elastic tissue nevi on front of the wrist, occasional similarity in nevi are sometimes associated with and a junctional nevus on the palm appearance. They are usually osteopoikilosis of underlying bones. or sole. familial, multiple, greater than 5 mm in diameter, with irregular edges, Epidermal nevi usually present as show a speckled surface and signs of rough warty lesions. They may be inflammation. They are important present at birth or develop later. because of their association with Closely associated with them are malignant melanomas. Periodic sebaceous nevi that usually occur examination is required for enlarging on the scalp as yellowish smooth lesions and melanomas even in bald areas. Though present at normal surrounding skin. Sporadic birth, they begin to become rough occurrence of such nevi does not and thick during puberty. They may have such sinister connotations. develop into a variety of tumours of the epidermis and its appendages. Fig. 2 : Pigmented and hairy mole Vascular nevi are red and indicate an Importance of these nevi lies in their

18 subjects they suggest later occurrence Persistent hair growth over of pigmented nevi. pigmented midline lesions warrants investigation for an underlying bone Café-au-lait spots are light to dark or spinal cord defect. Pigmentation brown, well defined macules, is often seen on one side of the face, usually 1 to 10 cm in size. One sclera and the meninges. It may be or two may be present on normal present at birth but usually develops skin and may disappear during adult later. On dark skin, brown and black life. More than six indicates the Fig. 1 : Linear epidermal nevus presence of generalized colours are frequent; they become neurofibromatosis. darker over a period of time. The association with systemic disorders sclera shows a well defined bluish- (epidermal nevus syndrome), the The large pigmented macules of black mark. Investigations for mildest being scoliosis. Bone Albright’s disease are similar to café- cerebral dysrrhythmia and bony tumours and cysts, au-lait spots but show irregular abnormalities of the skull are hypophosphataemia and vitamin D3 border. Fibrous dysplasia of bones indicated. resistant rickets are known in the monostotic form may associations. Almost any organ improve later in life. The Congenital melanocytic nevi (CMN) are system may be affected in the polyostotic variety worsens and usually present at birth or develop a epidermal nevus syndrome. may end as a sarcoma. Both types few days later. They are classified as Malignant change may occur within may be detected because of giant (20 cm or more in diameter), the epidermal component or in the fractured bones beneath pigmented medium (from 1.5 to 10 cm) and melanocytic nevi that develop as a macules. Endocrinal changes and small (up to 1.5 cm). They are part of the syndrome. A pigmented precocious puberty, usually in important because of the disorders mole may develop epidermal females, are often the presenting associated with them. If located on cancer because of altered signals the back especially near the midline, between the cells of the two features. spinal deformities and invasion of components. Lentigines represent an increase in the the meninges can occur. Club-foot, Freckles are brownish black pinhead number and function of melanocytes limb atrophy, lipomas and in the basal layer. They are sized or slightly larger spots flush neurofibromatosis are some of the macules 2-3 mm in diameter, with the skin surface (macules). When disorders found with CMN. Bathing- brown to black in colour, and present on the lips and oral mucosa trunk nevus is of the giant type. simulate freckles but do not from infancy or childhood, they may Melanomas arising from the deeper change in colour with solar be associated with polyps in the parts of these nevi need periodic protection or exposure as freckles gastrointestinal tract that could evaluation. In the usual mole the do. They occur with the become malignant later. Angiomas change usually arises in the superfical of the gastrointestinal tract are rare gastrointestinal disorders described portion. but can occur with freckles as above. They may be present sui described above. Persistent facial generis or indicate the presence of The above few examples illustrate freckles may be familial or indicate underlying cardiac, neurologic, how nevi act as pointers of systemic development of solar sensitivity skeletal and other defects especially changes and help in planning proper disorders such as xeroderma if they have a horizontal centrofacial investigation. pigmentosum. In fair skinned location.

Black moles on the palms if they can be included within a fist bring in plenty of money and those on the soles indicate travel. Fiction : Consult a doctor if moles on the palms and soles increase in size or number. VRM, NM

19 WELCOME

Dr. Gustad B. Daver His field of interest in Surgery is consultant. He did his MBBS from has joined as Director General surgery, thoracic surgery and Seth G. S. Medical College and his Professional Services vascular surgery, and development of M.S. (Ophthal.) and D.N.B. from JJ from July, 2004. multi-organ transplant programme. Hospital Mumbai. He then went to Chennai for advanced training in Dr. Daver was Dean, Dr. Daver has been recently awarded Professor & Head Lifetime Achievement Award from vitreoretinal disorders. There he Department of SEWA (Social & Education Welfare completed his Vitreoretina Surgery at Grant Medical College & Association) for meritorious services Fellowship from the world Sir J.J. Group of Hospitals, Mumbai. in the field of Medicine. renowned eye institute Sankara Nethralaya. Following his He worked as faculty in Surgery for Dr. Daver believes that discipline and fellowship he spent 3 years as a 25 years at Government Medical teamwork are essential for success. College, Aurangabad, Nagpur and Vitreoretina Consultant in Sankara Mumbai and was professor of Surgery Dr. Simran Singh, Nethralaya. While there he obtained at Grant Medical College & Sir J. J. MD, EDIC, joined his F.R.C.S. (Edin) degree. He has Hospital, Mumbai since 1990. He has the intensive care unit independently performed more than been a postgraduate teacher for 20 as a consultant 2000 complex vitreoretinal surgeries years and an examiner for MBBS. MS Intensins and a and more than 3000 retinal LASER and MCh (vascular surgery). physician. procedures. He is the author of Ophthalmology Theory and In addition he held administrative After gaining initial Practicals. He is also the co-author responsibilities as Vice Dean for 3 years experience in intesive care at P. D. of Fundus Fluorescein Angiography and Joint Director, Medical Education Hinduja National Hospital, she went Atlas of Sankara Nethralaya. and OSD for Government of to Melbourne, Australia for an Maharashtra for 2 years. He was a advanced fellowship in intensive care Dr. Samant aspires to establish at Member of the Board of studies for for nearly 4 years. P.D. Hindjua Hospital a vitreoretina surgery in Mumbai University & Unit of world class repute. Inspector for Medical Council of India. She worked at The Royal Melbourne Hospital, The Alfred and The Dr. Daver has done Postdoctoral RIA Laboratory Epworth hospitals and, gained Fellowship in Cardiovascular & New Investigations valuable experience in managing Multiorgan Transplant Surgery with polytrauma, post heart-lung • Tacrolimus for Kindney / world renowned Dr. Michael E. De Liver transplant patients Bakey at Baylor College of Medicine, transplant, post renal transplant and Houston, Texas, USA for 3 years. He burns patients, in addition to the • Markers for type I diabetes has been actively involved in routine general medical and surgical development and organisation of ICU patients. She acquired the • Vitamin B6 European Diploma in Intensive Care Transplant Programme for • Malabsorption / Coeliac in 2003. Government of Maharashtra and is a Disease Markers member of the ZTCC (Zonal Dr. Preetam Samant, • Change in existing service Transplant Co-ordination Cell) and M.S. (Ophthal.), names MCFOT (Maharashtra Confederation D.N.B., F.R.C.S. of Organ Transplant). He is a founder Atrial Natiuretic Peptide (ANP) and (Edin), F.C.P.S., member of the Vascular Society of Brain Natiuretic Peptide (BNP), M.N.A.M.S., has India and member of Transplant potent cardiovascular markers, are Society of India and Michael E. De joined as a full time now listed in our service menu as Pro ANP and ProBNP Nt. Bakey International Society. Ophthalmology

Printed and Published by Marketing Department, P. D. Hinduja National Hospital & Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai - 400 016 at SYNERGY CREATIONS, for free and private circulation. Editor : Dr. V. R. Joshi. Registered. (The Publisher cannot be held responsible for errors or for any consequences arising from the use of the information contained in this newsletter.)

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