Rajiv Gandhi University of Health Sciences, Bangalore s7

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE KARNATAKA ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 1. Name of the Candidate DR. AMRITA A. HONGAL, D/O DR. A. B. HONGAL, and Address CHIRANJEEVI HOSPITAL, (in block letters) BESIDES V. N. COLLEGE, HOSPET-583201. KARNATAKA.

2. Name of the Institution J.J.M. MEDICAL COLLEGE, DAVANGERE - 577 004. KARNATAKA.

3. Course of study and subject POST GRADUATE DEGREE – M.D. DERMATOLOGY, VENEREOLOGY AND LEPROLOGY 4. Date of Admission to course 06-06-2011 5. Title of the Topic “PALMOPLANTAR DERMATOSES- A CLINICAL STUDY OF 300 CASES”.

6. BRIEF RESUME OF THE INTENDED WORK: 6.1 Need for the study : Dermatological diseases affecting the palms and soles are very common in clinical practice and are among the most difficult ones to diagnose and treat. It is very important to recognize the symptoms and signs affecting palms and soles, since they may at times be limited to palms and soles, and also recognizing these signs may provide a clue to their associated general skin diseases and systemic disorders.2 Previously studies have focused on the specific diseases of palmoplantar dermatoses, however there is a lack of comprehensive study of palmoplantar dermatoses.1 Hence this study has been taken up to study the epidemiological and clinical aspects of the common palmoplantar dermatoses. 6.2 Review of literature :

Palms and soles have a non hairy or glabrous skin which is marked by series of ridges and grooves(sulci) with a configuration unique to each individual known as Dermatoglyphics. They have a thicker epidermis, a

2 complex dermo-epidermal junction and encapsulated sense organs within dermis and highest concentration of sweat glands but lack sebaceous glands, apocrine glands and hair follicles.

Palms and soles are affected by various dermatological diseases. Palms and soles in psoriasis may be affected alone or as part of generalized disease, at these sites psoriasis may present as discrete plaque – firm hyperkeratotic yellowish brown areas with adherent scales or as diffuse redness with overt scaling and a sharp line of demarcation between involved and uninvolved skin.2 Sterile pustular eruptions appear on palms and soles in Palmoplantar pustulosis, Acrodermatitis Continua and Infantile acropustulosis.

Eczema affecting the palms and soles may be due to exogenous or endogenous factors, exogenous includes irritant contact dermatitis and allergic contact dermatitis, and endogenous dermatitis includes atopic dermatitis, pompholyx, juvenile plantar dermatosis, recurrent focal palmar peeling and hyperhydrosis. Morphological types of eczemas include gut eczema, ring eczema, housewife eczema, finger tip eczema, discoid eczema and many more. Callosities and Corns results from adaptation of the skin to chronic external forces of friction and shear, and manifests as areas of hyperkeratosis which appear as rigid yellow coloured areas.2 Many bacterial, fungal and viral organisms can produce primary or secondary infections of palms and soles. Streptococcal infections like erysipelas, cellulitis and blistering distal dactylitis are common and result from entry of bacterium through fissure or other skin damage. Corynebacterial infections affecting palms and soles are erythrasma and pitted keratolysis. Erythrasma commonly presents as asymptomatic scaling, fissuring and maceration involving the webspaces of toes commonly 3rd and 4th. Pitted keratolysis usually involves the soles and presents as pale, edematous plantar skin with small punched out pits and is associated with hyperhydrosis. Tuberculosis when affects palms and soles present with granulomatous plaque, warty plaque or persistent ulceration. Leprosy also presents with fissuring and ulceration. Dermatophytic and

3 candidial infections of palms and soles are common. Dermatophytic infections of palms and soles called Tinea manum and Tinea pedis respectively presents as dry hyperkeratotic moccasin type, inflamed/vesicular spreading type, or interdigital type.2 Candida species are normal inhabitants of gastrointestinal tract, but rarely colonise the skin unless there is some break in the integument, for example dermatitis, cracks or fissures and commonly manifests as intertrigo affecting the interdigital spaces. Viral infections like verruca and hand-foot- mouth disease affect the palms and soles. Verruca caused by HPV infections are seen commonly in older children and young adults results from direct infection during playing and barefoot activities. Hand-foot-mouth disease caused by viruses of Picornaviridae family more commonly Coxsackie A virus and Enterovirus-71, affects infants and children quite commonly and presents with rashes over palms and soles followed by sores and blisters with associated systemic symptoms.

Palmoplantar keratoses(PPK) comprise a heterogenous group of disorders of keratinization, which can be subdivided into hereditary and acquired forms. Hereditary forms may be localized primarily to the hands and feet or be associated with more generalized skin diseases.6 They are divided into diffuse PPK, focal PPK, punctate PPK and palmoplantar ectodermal dysplasia.

Fixed drug eruptions are those which characteristically recurs in the same site/sites each time the drug is administered; with each exposure, however, the number of involved sites may increase. Palms and soles are one of the favoured sites for these fixed drug eruptions, presents as sharply marginated, round or oval itchy plaques of eythema and edema becoming dusky violaceous or brown, and sometimes vesicular or bullous.3

In Erythema multiforme minor; simplex or papular form the lesions are distributed preferentially on the distal extremeties usually affecting the palms. The lesions are dull red, flat or slightly raised maculopapules and typical cases may show at least some target/iris lesions.4

4 Keratoderma blennorrhagica is commonly seen as an additional feature of reactive arthritis/ Reiter’s syndrome- classical triad of urethritis, arthritis and conjuctivitis, presents as vesiculo-pustular waxy lesion with a yellowish brown colour usually affecting palms and soles but may also involve scrotum, scalp and trunk.

Tumours developing on palms and soles, may be benign or malignant. Common benign tumours include cutaneous horn, dermatofibroma, eccrine poroma, epidermal cyst, gaint cell tumour of tendon sheath, glomus tumour, granuloma pyogenicum, hemangioma, nevus and keloid. Common malignant tumours include malignant melanoma, squamous cell carcinoma and kaposi’s sarcoma.

Epidermolysis bullosa consists of group of diseases characterized by an increased tendency for the skin to blister, mostly inherited but may be acquired and affects the feet and less commonly hands. Palms and soles are affected in certain errors of metabolism like carotenaemia, hyperbilirubinemia and hyperlipidemia. Certain psycho-cutaneous dermatoses may affect palms and soles like lichen simplex chronicus, prurigo nodularis and dermatitis artefacta.

Miscellaneos conditions affecting palms and soles are urticaria, vitiligo, erythema nodosum, palmar erythema of pregnancy and symmetric lividity of the soles.

6.3 Objectives of the study : 1) To study the epidemiological aspects like relative incidence, age distribution & sex distribution in 300 cases of palmoplantar dermatoses randomly selected from those attending OPD at the Department of Dermatology, J. J. M. Medical College, Davangere. 2) To study the frequency of the palmoplantar dermatoses according to locations ie

5 involving palms, soles or both palms and soles. 3) To study the clinical features of the various palmoplantar dermatoses. 4) To study histopathological features in selected cases.

6 7. MATERIALS AND METHODS: The study is a cross sectional study. 7.1 Source of data : The study group will be drawn from patients attending the OPD of Department of Dermatology, at C. G. Hospital and Bapuji Hospital, attached to J. J. M. Medical College, Davangere, for a period of 2 years from October 2011 to September 2013. 7.2. Method of collection of data (including sampling procedure if any): A minimum of 300 patients with palmoplantar dermatoses belonging to all age groups and both sexes will be randomly selected and included in the study after taking their consent. In each case a detailed history will be taken, and a thorough general physical, local and systemic examination will be carried out according to prestructured proforma. Inclusion criteria : - Patients selected are those attending the department primarily with complaints pertaining to palms and soles, irrespective of age, sex and immune status. Exclusion criteria : - Patients who have already been diagnosed and receiving treatment for palmoplantar dermatoses.

7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly. -Gram’s staining -KOH examination for fungus -Wood’s Lamp Examination -Patch testing -Biopsy 7.4. Has ethical clearance been obtained from your institution in case

7 of 7.3? -YES

8 8. REFERENCES: 1) A Clinicopathological Study of Palmoplantar Dermatoses: Kang BS, Lee JD, Cho SH, Department of Dermatology, Our Lady of Mercy Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. 2) Text Atlas of Podiatric Dermatology: Rodney Dawber, Ivan Bristow, Warren Turner, 1st Edition, London, U K, Martin Dunitz Ltd, 2001. 3) Drug reactions- Chapter 75, S M Breathnach, Rook’s Textbook of Dermatology, 8th Edition, John Wiley & Sons Ltd, 2010.

4) Erythema Multiforme, Steven-Johnson Syndrome and Toxic Epidermal Necrolysis- Chapter 76, S M Breathnach, Rook’s Textbook of Dermatology, 8th Edition, John Wiley & Sons Ltd, 2010.

5) Pasricha J S. Contact dermatitis in India, 2nd ed. New Delhi : Offsetters, 1988.

6) Lucker GPH, Vandekerkhof PCM, Steiljen PM- The Hereditary Palmoplantar Keratoses- an updated review and classification. Br J Dermatology 1994; 131:1- 14 9. Signature of candidate

10 Remarks of the guide Recommended and forwarded for study.

11 Name & Designation of (in block letters) 11.1 Guide Dr. NADIGA RAJASHEKHAR, M.D, D.V.D PROFESSOR, DEPARTMENT OF DERMATOLOGY, VENEREOLOGY AND LEPROSY, J.J.M. MEDICAL COLLEGE, DAVANGERE - 577 004. 11.2 Signature

9 11.3 Co-Guide (if any) - -

11.4 Signature - -

11.5 Head of the Department Dr. S.B. MURUGESH M.D., F.A.M.S., PROFESSOR AND H.O.D., DEPARTMENT OF DERMATOLOGY, VENEREOLOGY AND LEPROSY, J.J.M. MEDICAL COLLEGE, DAVANGERE - 577 004. 11.6 Signature

12 12.1 Remarks of the Chairman & Principal

12.2. Signature.