Letters to Editor risks should be considered as an adjuvant to any therapeutic DNCB powder was dissolved in acetone and diluted in protocol for patients with psoriasis appropriate concentrations of 0.001%, 0.01%, 0.05%, 0.1%, 0.5%, 1%, 1.5% and 2% solutions. Solution was stored in dark RRaghavendraaghavendra Rao,Rao, SmithaSmitha Prabhu,Prabhu, H.H. SripathiSripathi bottles until use in room temperature. DNCB was applied Department of Skin and VD, Kasturba Medical College, Manipal, India using cotton buds. Sensitization was done by applying 2% DNCB over 4 x 4 cm area on back during the first visit. After 1 AAddressddress fforor ccorrespondence:orrespondence: Dr. Raghavendra Rao, Department of Skin and V.D. Kasturba Medical College, Manipal, Karnataka- 576 week, weekly applications of DNCB were done starting with 104, India. E-mail: [email protected] lowest concentration (0.001%) to the affected area of . Patients were advised to avoid washing the area and RREFERENCESEFERENCES protect it from sunlight for 48 hours. Applications of DNCB were repeated weekly with increasing concentrations. Aim 1. Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin was to produce moderate eczema. Mild to moderate eczema DM. Psoriasis causes as much disability as other major was maintained by titrating the DNCB concentrations. The medical diseases. J Am Acad Dermatol 1999;41:401-7. patients were advised to inform about any side effects 2. Reed WB, Becker SW, Rhode, Heiskell CL. Psoriasis and arthritis: A clinicopathological study. Arch Dermatol during the treatment period. If there was no sensitivity after 1961;83:541-8. 12 weeks, it was considered as treatment failure and the 3. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, patient was withdrawn from the study. Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA 2006;296:1735-41. A total of 22 patients were included in the study. The 4. McDonald CJ, Calabresi P. Psoriasis and occlusive vascular total duration of the study was 6 months. All the patients disease. Br J Dermatol 1978;99:469-75. completed the study period. Out of 22 patients, 2 patients 5. McDonald CJ. Cardiovascular complications of psoriasis. In: had only beard involvement, 8 had only scalp, 3 had ophiasis Roenigk HH, Maibach HI, editors. Psoriasis. 2 nd ed. New pattern, 5 had and 4 had . York: Marcel Dekker Inc; 1991. p. 97-111. 6. Wakkee M, Thio HB, Prens EP, Sijbrands EJ, Neumann HA. Complete hair growth with terminal hairs was seen in Unfavourable cardiovascular risk profiles in treated and 8 (36.36%) patients and 4 patients did not respond at all. untreated psoriasis patients. Atherosclerosis 2007;190:1-9. Remaining 10 patients had variable response. Side effects 7. Ludwig RJ, Schultz JE, Boekncke WH, Podda M, Tandi C, observed during the study period were hyperpigmentation, Krombach F, et al. Activated, not resting, platelets increase irritation, fever and lymphadenopathy. Six months of follow- leukocyte rolling in murine skin utilizing a distinct set of up was done in 20 patients, 2 patients were lost to follow-up. adhesion molecules. J Invest Dermatol 2004;122:830-6. Two patients with complete hair growth developed patchy 8. Malerba M, Gisondi P, Radaeli A, Sala R, Calzavara Pinton hair loss after 3 months during the follow-up period. PG, Girolomoni G. Plasma homocysteine and folate levels in patients with chronic plaque psoriasis. Br J Dermatol 2006;155:1165-9. The only disadvantage of DNCB is its mutagenicity by Ames test. However, drugs like norfloxacin, isoniazid and psoralen with ultraviolet A (PUVA) treatment, textile dyes and fumes of oils have also been found mutagenic by Ames test.[5-7] The TTopicalopical ddinitrochlorobenzeneinitrochlorobenzene most potent mutagenic agent in early trials of Ames test is ((DNCB)DNCB) forfor aalopecialopecia areata:areata: parsnip juice. DNCB was found non-carcinogenic when fed in large doses in rats, mice, guinea pigs and man. Happle RRevisitedevisited and Edternacht et al,[5] had a good response with DNCB. The effect was seen in all 7 patients with moderate hair loss, in 12 out of 13 patients with extensive hair loss and in 14 out Sir, of 23 patients with totalis. Treatment was Treatment of alopecia areata with topical immunotherapy successful in 26 out of 31 patients with a history of duration by contact sensitizers is an effective and accepted of disease 5 years or less and 7 out of 12 patients with therapeutic modality in the treatment of chronic severe history of more than 5 years. There is renewed interest in the alopecia areata.[1,2] The contact sensitizers used in alopecia immunomodulatory effects of topical DNCB in patients with areata are dinitrochlorobenzene (DNCB), diphenyl-cyclo- human immunodeficiency virus (HIV) infection and systemic propenone (DPCP)[3] and squaric acid dibutyl ester (SADBE). lupus erythematosus.[7] During almost 10 years of topical We used DNCB in the treatment of chronic resistant DNCB therapy in HIV patients world wide, the only reported alopecia areata.[4] side effect has been localized dermatitis at the application

Indian J Dermatol Venereol Leprol | July-August 2008 | Vol 74 | Issue 4 401 Letters to Editor site.[8] We believe that in view of the reports of efficacy of caused by a group of closely related fungi known as DNCB therapy,[9,10] DNCB requires a relook as an option in dermatophytes while the term dermatomycosis includes alopecia areata rather than other contact sensitizers that dermatophytoses and infections by non-dermatophyte are available only with difficulty and are expensive.[11] molds.[1-3] The clinical presentation may often be confused with other skin disorders due to the rampant application KK.. HH.. MMohan,ohan, CC.. BBalachandran,alachandran, SS.. DD.. SShenoi,henoi, of broad-spectrum steroids and other ointments. We, at RRaghavendraaghavendra Rao,Rao, SripathiSripathi H,H, PrabhuPrabhu SmithaSmitha the Department of Microbiology studied the occurrence Department of Dermatology, Kasturba Medical College, Manipal, of common and uncommon prevailing fungi causing Karnataka, India dermatomycosis. AAddressddress fforor ccorresspondence:orresspondence: Dr. Mohan K H, Assistant Professor, Department of Dermatology, KMC, Manipal – 576 104, Udupi, Out of 328 suspected cases of dermatomycosis, a total of 99 Karnataka, India. skin scrapings, 62 scalp hair samples and 166 nail samples were processed in the period of 2005–2006. Microscopy RREFERENCESEFERENCES using 10% KOH was followed by cultures on modified Sabouraud’s dextrose agar (SDA) with chloramphenicol 1. Breuillard F, Szapiro I. Dinitrochlorobenzene in alopecia areata. Lancet 1978;2:1304. (0.05 mg/mL) and cycloheximide (0.5 mg/mL). Fungal 2. Cotteril JA, Psychiatry and skin diseases. In: Rook AJ, species were identified by cultural characteristics, pigment Maibach HI,editors. Recentadvances in dermatology No.6. production, rates of growth, lactophenol cotton blue (LPCB) Edinburgh: Churchill Livingstone; 1983. p. 189-212. preparations and slide cultures on potato dextrose agar 3. van der Steen PH, van Baar HM, Happle R, Boezeman JB, (PDA). The urease test was used to differentiate between Perret CM. Prognostic factors in the treatment of alopecia T. rubrum and T mentagrophytes. SDA was used to identify areata with diphenylcyclopropenone. J Am Acad Dermatol Candida spp with the aid of LPCB preparations. In addition, 1991;24:227-30. the germ tube (GT) test, growth on corn meal agar (CMA) 4. Warin AP. Dinitrochlorobenzene in alopecia areata. Lancet [1] 1979;3:927. and sugar assimilation tests were also used. 5. Happle R, Echternacht K. Induction of hair growth in alopecia areata with DNCB. lancet 1977;2:1002–3. Out of 99 skin scrapings, fungal elements could be seen in 6. Rokhsar CK, Shupack JL, Vafai JJ, Washenik K. Efficacy of 25 cases and culture was positive in 15 cases (15.15%). Out topical sensitizers in the treatment of alopecia areata. J Am of these 15 isolates, T. rubrum was isolated in 40% (6/15) Acad Dermatol 1998;39:751–61. cases, T. violaceum in 26.66% (4/15) cases, T. mentagrophytes 7. Stricker RB, Elswood BF. Dendritic cells and was isolated in 13.13% (2/15), T. schonlenii, Fusarium spp. and dinitrochlorobenzene (DNCB): A new treatment approach to Exophiala spp. were isolated in one case each. AIDS. Immunol Lett 1991:29:191–6. 8. Stricker RB, Elswood BF. Topical dinitrochlorobenzene in HIV disease. J Am Acad Dermatol 1993;28:796–7. Eight (12.69%) dermatophyte species were isolated from 63 9. Singla A, Mittal RR, Walia RL, Bansal IJ. Comparative efficacy hair samples collected from scalp hairs. Among the culture- of topical DNCB and PUVASOL therapy in alopecia areata. positive hair samples, the most common organism isolated Indian J Dermatol Venereol Leprol 1991;57:284-6. was T. violaceum (62.5%, 5/8), while Microsporum gypseum, 10. Khopkar U, Nigale V, Trasi SS, Wadhwa SL. Topical T. mentagrophytes and T. schoenleinii were isolated from dinitrochlorobenzene (DNCB) in alopecia areata. Indian J endothrix cases. Dermatol 1990;35:103-6. 11. Singh G, Okade R, Naik C, Dayanand CD. Diphenylcyclopropenone immunotherapy in ophiasis. Indian From 166 cases of nail samples, cultures were positive in 27 J Dermatol Venereol Leprol 2007;73:432-3. cases (16.26%). Of these 27 cases, the most common isolate was T. violaceum (22.22%, 6/27) followed by T. tonsurans in 14.81% cases (4/27). T. rubrum, T. mentagrophytes, C. albicans, C. DDermatomycosisermatomycosis causedcaused byby tropicalis, each comprised 11.11% of the 27 cases. E. flocossum, T. schonlenii, C. parapsilosis, C. krusei and Scopulariopsis spp. ccommonommon andand rarerare fungifungi inin were isolated from one case each. Blue-collar workers (74.07%, 20/27) followed by housewives (25.92%, 7/27) were MMumbaiumbai commonly found to suffer from .

Sir, In our study, T. rubrum was the most common isolate from Dermatophytoses are the infections of keratinized tissues the skin in 40% (6/15) of culture positive cases, followed by

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