The Efficacy and Safety of Eberconazole Nitrate 1% and Mometasone Furoate 0.1% w/w Cream in Subjects with Inflamed Cutaneous Mycoses

BACKGROUND

Topical antifungal agents along with the steroids may provide not only rapid symptomatic relief but also clearance of disease causing fungi in inflamed cutaneous mycoses (ICM).

AIM

To assess the efficacy and safety of fixed dose combination (FDC) of Eberconazole nitrate 1% and Mometasone furoate 0.1% w/w cream, in subjects with ICM.

METHODS

This was a multi-centric, non-comparative study conducted in 155 eligible adult Indian subjects with ICM. They were treated with study medication for 21 days (D21) and followed up on day 35 (D35). Efficacy (by Investigator's Static Global Assessment-ISGA, symptom severity scores) and safety were assessed to evaluate the therapeutic response.

RESULTS

Of 155 subjects, 129 completed the study. Lesions healed completely in 77.52% and improved markedly in 22.48% patients by D21. There was a statistically significant reduction (p<0.001) in total symptom score (TSS) and mean severity scores of erythema, scaling and pruritus on days 7 and 21 compared to baseline. There was no treatment failure. Only 11 patients remained culture positive on D21 compared to 68 at baseline. Physicians evaluated the drug as 'Good' in 72% and 'Excellent' in 28% of subjects; adverse events were reported in 27.74% subjects and none was severe. There was a decrease in serum cortisol level in 4.52% (7/155) subjects and was considered clinically significant in three subjects. On D35, 18.55% and 24.20% subjects had greater ISGA score and TSS respectively, compared to D21.

CONCLUSION

Tested FDC demonstrated efficacy and was well tolerated by study population. It offers an effective and safe therapeutic option for the management of ICM.

Generalized eruptive syringoma

Eruptive syringoma is a very rare variant of syringoma. It is a benign adnexal tumor of the intraepidermal portion of eccrine sweat ducts. Here we report a 32-year-old female presented with classical asymptomatic eruptive syringomas involving her face and extremities.

Rowell's Syndrome to ds-DNA Negative Lupus Nephritis: A Yet Unreported Progression

Rowell's syndrome is now identified as a subtype of subacute lupus erythematosus (LE) with erythema multiforme-like skin lesions, positive serum rheumatoid factor, anti-Ro La positivity and speckled pattern of antinuclear antibodies. Here we describe a case of Rowell's syndrome in an 18-year-old female who was found to be ds-DNA negative, who later progressed to develop stage V lupus nephritis (LN) over a course of 4 months. Although extremely rare, most cases of LN are drug induced. Of only seven cases of non-drug induced LN with negative dsDNA, none had cutaneous involvement. Ours was a unique case of progression of Rowells syndrome to ds-DNA negative LN.

Late onset palmar angiokeratoma circumscriptum: An unusual presentation

Angiokeratomas (AK) are a group of capillary vascular malformations encompassing several unrelated conditions, predominantly seen on the lower extremities. AK can be classified into localized and diffuse forms. The diffuse forms comprise Fabry's disease, which is the result of α-galactosidase deficiency. The cutaneous AK includes the Mibelli type, the Fordyce type, angiokeratoma circumscriptum (AC), and ‘solitary and multiple papular angiokeratoma’. We describe a case of AC with unusual features including late onset and palmar affection. Amongst the possible therapeutic options, cryotherapy was considered. However, the patient was lost to follow up.

Hereditary angioedema: not an allergy

Hereditary angioedema is a genetic disorder due to a deficiency or malfunction of C1 esterase inhibitor. We herein describe a case of 25-year-old male who presented with swelling over face since one day. There was history of similar episodes since two years with gradual subsidence of swelling without any treatment. Investigations revealed grossly reduced complement C4 and C1 esterase inhibitor level. Patient was diagnosed to have hereditary angioedema type 1 and started on stanozolol 2 mg three times a day with no recurrence in one year of follow-up. Hereditary angioedema resembles angioedema of an allergic reaction. However, the cause is different.

Efficacy and safety of topical halometasone in eczematous dermatoses in Indian population: an open label, noncomparative study

BACKGROUND

Topical steroids remain the mainstay of treatment in eczema, an inflammatory skin reaction characterized by pruritus, redness, scaling, and clustered oozing papulovesicles. Halometasone is a new potent corticosteroid approved in the Indian market for topical application in the treatment of dermatitis.

AIMS

To evaluate the efficacy and safety of halometasone in the treatment of acute or chronic noninfected eczematous dermatosis in Indian population.

MATERIALS AND METHODS

A prospective, open, multicentric, phase 3, noncomparative clinical trial conducted at outpatient departments of seven centres. Two hundred endogenous eczema patients meeting study criteria were enrolled. Halometasone 0.05% cream was applied twice daily for 30 days in chronic and 20 days in acute eczema patients. Calculation of eczema area and severity index, and assessment of investigator's global assessment of severity of eczema and severity of pruritus score were done at each visit and compared with baseline. All adverse events (AE) were captured and documented. Laboratory investigations including haematological tests, urinalysis, renal and liver function tests were performed at baseline and at end of treatment.

RESULTS

Of the 200 patients enrolled, 180 were chronic and 20 were acute eczema patients. It was found that there was a significant (P<0.001) improvement in all efficacy parameters compared with baseline. The treatment was shown to be successful in 91% patients. AE were reported in 30 patients and there was no serious AE reported. There was no clinically significant difference in laboratory investigations with treatment.

CONCLUSIONS

Halometasone was shown to be safe and very effective in Indian patients with acute and chronic eczema and the drug was well tolerated.

Hematohidrosis - a rare clinical phenomenon

Hematohidrosis is a very rare condition of sweating blood. A case of hematohidrosis is reported. There are only few reports in the literature.

Dyskeratosis congenita with portal hypertension of unknown etiology

Dyskeratosis Congenita (DKC) is a rare progressive bone marrow disorder associated with multi-systemic involvement. It is also characterized by triad of abnormal skin pigmentation, nail dystrophy and mucosal leukoplakia. Liver cirrhosis and portal hypertension are said to be uncommon among these patients. We hereby report a case of an adult male who presented with pancytopenia, abnormal skin pigmentation, nail dystrophy and mucosal leukoplakia. Skin biopsies along with clinical features confirmed the case. Imaging studies were reported as suggestive of and portal hypertension. Liver biopsy done but non-conclusive. Patient's one son and one daughter also had similar skin pigmentation.

Atypical presentation of leprosy in HIV

Atypical presentations can be expected when leprosy, a mycobacterial disease is associated with HIV. We report a case of a 28 year old male driver with a high risk behavior, who came for evaluation of hypoaesthetic, scaly erythematous plaques over face, trunk, upper extremity; verrucous lesions over elbows and necrotic lesions over the neck and lower extremities since 6 months. No other systemic complaints were present. Nerve examination showed grossly thickened left greater auricular nerve and cord like thickening of bilateral ulnar and lateral popliteal nerves. His investigations revealed anemia, a reactive ELISA for HIV-1 and CD4 of 400 cell/cmm. Ultrasonography of the thickened nerves revealed an abscess in the left ulnar nerve whereas the left greater auricular nerve showed neuritis. Histopathology from an erythematous plaque was suggestive of borderline tuberculoid leprosy in reaction. Final diagnosis was borderline tuberculoid leprosy in type 1 reaction with atypical and varied morphology in an immunocompromised male with neuritis of the left greater auricular nerve, a silent left ulnar nerve abscess with early left ulnar nerve palsy. Our case highlights the atypical morphology of leprosy lesions and the unexpected protective cellular response as suggested by formation of nerve abscess in a HIV positive patient.

Men who have sex with men and transgenders in Mumbai, India: an emerging risk group for STIs and HIV

BACKGROUND

Men who have sex with men and transgenders are an important risk group for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). They have risky sexual behaviors but low risk perception.

OBJECTIVES

To assess the sexual behavior, STIs, HIV and identify factors associated with HIV in men who have sex with men (MSM) and transgenders (TGs) in Mumbai.

METHODS

Participants were enrolled from two clinics in Mumbai. They completed an interviewer-administered questionnaire and were evaluated for STIs and HIV infection.

RESULTS

A total of 150 participants, 122 MSM and 28 TGs were evaluated; 17% of MSM and 68% of the TGs were HIV infected. HIV infection in MSM was associated with serological positivity for HSV2 IgG [adjusted odds ratio (aOR), 95% confidence interval (CI): 9.0 (2.2-36.9)], a positive Treponema pallidum hemagglutination assay (TPHA) [aOR (95% CI): 6.0 (1.5-24.0)], greater than five acts of receptive anal sex in the past six months [aOR (95% CI): 4.3 (1.2-15.0)] and per category increase in age (18-24 yrs, 25-29 yrs, > 30 yrs) [aOR (95% CI): 3.1 (1.3-7.1)] in multivariate analysis. Consistent condom use during receptive anal sex in the past six months was low (27%). Many MSM were married (22%) or had sex with females and may act as a 'bridge population'. HIV infection in TGs was associated with a positive TPHA [OR (95% CI): 9.8 (1.5-63.9)] and HSV 2 IgG [OR (95% CI): 6.7 (1.1-40.4)] in univariate analysis.

CONCLUSION

Prior STIs were strongly associated with HIV infection in MSM and TGs. These groups should be the focus of intensive intervention programs aimed at STI screening and treatment, reduction of risky sexual behavior and promotion of HIV counseling and testing.

Blastomycosis-like pyoderma

A 9-year-old female, presented with recurrent bilaterally symmetrically distributed flesh colored vegetative plaques, papules and nodules on trunk and upper and lower extremities since 15 days. Investigations revealed anemia, hypoproteinemia, decreased albumin and positive D-xylose test. Pus swab and biopsy for culture sensitivity showed Enterococci species. Biopsy showed spongiotic psoriasiform dermatitis with subcorneal pustule. She fulfilled criteria for the diagnosis of blastomycosis-like pyoderma viz. presentation of large verrucous plaques with pustules and elevated border, pseudoepitheliomatous hyperplasia with abscess histologically and growth of one pathogenic bacterium on culture or tissue biopsy. She responded to long-term amoxicillin-clavulanic acid therapy.

A comparative clinico-pathological study of single dose ROM in paucibacillary leprosy patients with 1-3 skin lesions

A controlled clinical and histopathological study was carried out to compare the efficacy of a combination of rifampicin 600 mg plus ofloxacin 400 mg plus minocycline 100 mg (ROM) administered as a single dose with that of standard WHO/MDT-PB six months' regimen with regard to resolution of lesion clinically and histopathologically. Skin biopsy was performed at the intake and at 6 months. The study subjects were 32 previously untreated, smear-negative patients, without nerve trunk involvement and having 1-3 skin lesions. The results were analyzed for mean clinical score for marked, moderate and no improvement and mean histopathological score was graded as active, resolving and complete resolution, according to granuloma fraction at the end of 6 months. Marked clinical improvement was seen in 25% and 12%, moderate improvement in 50% and 56% patients treated with ROM and standard regimens respectively. Histopathologically, activity was seen in 62.5% and 43.7% and resolution of granuloma in 25% and 31.2% in the ROM and standard regimens respectively. Both the regimens were equally efficacious in the reduction of clinical score and granuloma fraction. No adverse drug reactions or reversal reactions were seen during the study period in both the groups.

Giant lobulated seborrheic keratosis at an unusual site

Seborrheic Keratoses(SK) are common benign skin tumors of elderly occurring commonly on face, scalp, extremities, chest, back with genital and perianal sites being rare. Lesions are usually few millimeters to several centimeters, reaching pendulous proportions in areas of constant friction, especially in obese individuals. Though malignant transformation is rare, it is reported in irritated lesions, especially in flexures. An unusual case of giant lobulated seborrheic keratoses occurring in perianal area, without any evidence of malignancy on histopathology, in an otherwise healthy obese female is reported here.

Role of different valence states of chromium in the elicitation of allergic contact dermatitis

Chromium, a known contact sensitizer, is present at high levels in certain detergent bars (40-50 p.p.m.) sold in India. A concern was whether chromium present in such detergent bars could sensitize users or their use lead to the elicitation of allergic contact dermatitis. Chromium present in detergent bars was analyzed for its valence state. It was found to be trivalent [Cr (III)] and not hexavalent [Cr (VI)]. An elicitation test on normal volunteers, as well as on volunteers who were sensitive to chromium, was carried out to determine the elicitation potential of chromium (III) in the bars. Of the 48 volunteers who completed the study, 30 did not show any positive response to either potassium dichromate, the positive control, or the detergent bar containing chromium (III). 18 volunteers who were identified as chromium-sensitive showed a positive response to potassium dichromate but not to the detergent bar containing trivalent chromium. This study clearly showed that the detergent bar with 40-50 p.p.m. of trivalent chromium did not elicit any allergic contact dermatitis even in individuals known to be chromium-sensitive. Hexavalent chromium (potassium dichromate) did however, elicit allergic contact dermatitis in these subjects.

Evaluation of salt split technique of immunofluorescence in bullous pemphigoid

Recent studies suggest that salt split skin is a more sensitive substrate than intact skin for immunofluorescence diagnosis of bullous pemphigoid. We undertook this study to define the role of salt split technique of immunofluorescence findings in 32 clinical and histopathology confirmed cases of bullous pemphigoid. Both direct and indirect immunofluorescences were performed using normal and split skin. Direct immunofluorescence positivity of 100% was noted with both routine and salt split method. Additional immunoreactant deposition was noted with direct method on split skin in 5 cases. Patterns of fluorescence in the latter were roof (40.60%), floor (9.4%) and combined roof and floor (50%). On indirect immunofluorescence, positivity was almost doubled with salt split technique ( 68%) as compared to routine method (36%). Thus, salt split technique was equivalent to routine on direct method in positivity with additional immunoreactant deposits noted in some and had double the sensitivity of the indirect method in detecting immunofluorescence in bullous pemphigoid.

Evaluation of clinical efficacy and safety of once daily topical administration of 1% oxiconazole cream and lotion in dermatophytosis : an open label, non comparative multicentre study

The clinical efficacy and safety of once daily topical administration of 1% oxiconazole cream and lotion was assessed in an open label, non comparative trial in tinea cruris, tinea corporis and tinea pedis patients. In treated patients, severity scores of erythema, pruritus, scaling, vesicles, papules and burning showed a progressive fall over a period of 4 weeks at all the study centres. With lotion, mean percentage improvement of symptoms varied from 35% (week 1) to 87.6 - 98.7% (week 4). With cream, it varied from 35% (week 1) to 82.5 - 99.5% (week 4). Overall global evaluation response showed clear, excellent and good response in 60%, 21% and 17% of the patients treated with lotion respectively. With cream, excellent and good response was observed in 71%, 10% and 16% of the patients respectively. In T. pedis patients, clear, excellent and good response was observed in 4/8, 2/8 and 1/8 patients respectively with lotion. Cream showed clear (8/15), excellent (4/15) and good (1/15) in these patients. None of the patients out of 178 enrolled, reported any side effect during the trial.

Comparative biorelease study of fluticasone in combination with antibacterial (Neomycin) and or antifungal (coltrimazol, miconazole) agents by histamine percutaneous reaction method in healthy volunteers

Fluticasone propionate is a novel, potent and topically active synthetic corticosteroid preparation with a much reduced potential, in relation to its anti-inflammatory potency, for unwanted systemic side effects. It is indicated for the treatment of eczema, dermatitis etc. The objective of the present study was to evaluate and compare the biorelease of fluticassone with placebo (base formulation); its combination with antifungal (miconazole, clotrimazole) and / or antibacterial agents based on the attenuation of histamine induced wheal and flare reaction and flare intensity (on visual analouge scale) by McNemar test. In the present study, fluticasone alone and in combination with clotrimazole, miconazole and neomycin significantly reduced the wheal and flare response of histamine prick test. The flare intensity response was also significantly inhibited by these treatments. Furthermore, there was no difference in the anti-inflammatory activity of various treatment groups. It may, therefore, be concluded that antibacterial (neomycin) and / or antifungal (miconazole, clotrimazole) agents in combination with steroid (fluticasone) do not alter the pharmacodynamic response of the latter.

Sezary syndrome in a young woman

A young female patient suffered for 4 months from a widespread erythrodermic rash of unknown origin, marked by a peculiar hyperaesthesia. Haematological and biopsy findings were initially non-specific. A rapid deterioration, accompanied by infiltration of the skin, lymphadenopathy and hepatosplenomegaly was suggestive of Sezary syndrome, which was confirmed by finding of 40% of the lymphocytes being atypical (Sezary cells).