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SKIN DOCTORS COMMUNIQUE

Info on Skin, Hair, Allergy & Cosmetology


Volume : 01 No. 03
For the use of Registered Medical Practitioners, Hospitals & Laboratories
May 2014
Chief Advisor
Editor - in - Chief
Executive Editors
Assistant Editors
Managing Editor
Office Staffs
Marketing Manager
Graphics
Prof. Rathindra Nath Dutta
Dr. Asim Kumar Sarkar
Dr. Joyeeta Chowdhury
Dr. Avijit Mondal
Dr. Indrajit Das
Dr. Ashim Kumar Mondal
Dr. Niharika Ranjan Lal
Dr. Naren Pandey
Soumitra Chattopadhyay
Samaresh Jana
Bishnu Charan Panda
Abhijit Paul
Sraboni Santra
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SKIN DOCTORS COMMUNIQUE
Definition :
TYPES :
CAUSATIVE FACTORS : DRUGS
FOOD
INFECTION
INHALANTS :
INVESTIGATION :
TREATMENT:
Urticaria is vascular condition of skin characterised by Erythema and wheals
peripherallysurroundedbyredhaloandpersistent severeitching, stinglingandirritation
The Subcutaneous swelling along with angioedema may involve respiratory and gastrto-
intestinal systemandsometimes therecanbesituationlikeanaphylaxyx andhypotention.
It can be Acute when it remains on the body for few days to weeks and resolves with or without
medications, andwhenit persists for morethan6weeks it is Labeledas Chronic Urticaria.
most common cause of acute Urticaria is Drugs- Penicillin, Asprin,
Sulphonamides, Tetracyclines, NSAIDs , Imidazoles, andchemicals usedfor foodpreservation.
Food is the next common cause of Acute Urticaria , it has also to be taken care for Chronic Urticaria
Cases, Common foods that can cause Urticaria are- Egg, Prawn, Hilsa Fish, Mutton, Beef, Pork, Crab, Sea
Food, among nonveg items andvegetables likeBringal, Pumpkin, NeemLeaf, Coconut, Banana, Pea nuts , &
other nuts, Lentils (Dal) milkandChocolates.
Many kinds of infections can attribute for urticaria, Streptococcal infection, Helicobacter
Pylori, Viral Hepatitis B& C, Parasites likeAscariasis, Filaria, Trichomoniasis, etc.
House Dust Mites, Grass Pollens, Animal Danders, Cosmetic Aerosols, Mosquito repellents,
evencottonusedinthepillowcanbeacausativefactor.
As a whole Urticaria is a huge topic to discuss at length within this limited space is not feasible, moreover
our readers must keep their eyes ears open to find out the trigerring factors like internal tumors, hormonal
imbalance, menthol likesubstances andmost importantlyemmotional stress.
it has to be tailor made as per thorough history taking followed by associated signs and
symptoms and then complete physical examination, if there is history suggestive of Sinusitis, a simple
digital X-Ray of PNSD may give us the clue in areas where parasitic infestation is prevalent, a blood count
showing eosionophillia would be helpful, we can also use Skin Prick Test (Challenge Test) and now a days
allergen Specific Serological Allergy Tests are available to give us a reasonable
gooddiagnosis.
TheDiagnosis of urticariais usuallyandessentiallymadeonclinical grounds.
1. Anti-Histamines-Oral non sedative medications are preferred, e.g
fexofenadine, desloratadine, famotidineandebastatin.
2. Cetirizinehydroxizines arealsoeffectiveinurticariabut cancausedrowsiness.
3. Systemic Corticosteroidc canbeappliedbut canbeusedintaperingmodebut not morethan3weeks.
4. Topical Soothing lotions may give some relief as can be seen with short termtopical steroid lotions,but
for the stubborn urticarial cases you may need to use immunosuppressive therapy, that may include
Azathioprine, Cyclosporine, Methotrexate, Omalizumab etc. in extreme cases we may have to go for
plasmapheresis or intravenous immunoglobulins(IVIG).
Editorial
Dr. Asim Kumar Sarkar
H.O.D Dermatology, E.S.I.C PGIMSR & ESIC Medical College, Joka
An overview of Urticaria (Hives)
Prof. (Dr.) Rathindra Nath Dutta
HOD, Dermatology, Columbia Asia Hospital
Light is essential for the survival as various physiological processes are
dependent on exposure to sunlight. The deleterious effect of sun on skin is
nowa major concernamong themedical fraternity particularly intheIndian
scenario where exposure to sunlight is high due to their skin type
(FitzpatrickIV/V) whichpredisposethemtanveryfrequently.
Solar UVradiation reaching the earth is a combination of UVB(290-320 nm)
and UVA (320-400 nm) wavelengths. Acute as well as chronic sun exposure
to UVB rays induce biological and clinical damage, such as sunburn,
photoagi ng, ski n i mmunosuppressi on, photodermatoses and
photocarcinogenesis frequently by it's energetic photons compared to UVA
rays.
With our increasing knowledge on the harmful effects of UVA, the need for
effective, well-balanced photoprotection has become more crucial to
minimizethedeleterious effect of ultraviolet rays.
Sunscreens have been divided into chemical absorbers and physical
blockers on the basis of their mechanism of action. The concept of the sun
protection factor (SPF) is defined as the ratio of the least amount of
ultraviolet energy (UVB) required to produce
minimal erythema on sunscreen-protected skin to
theamount of energy requiredtoproducethesame
erythema on unprotected skin . Asunscreen with a
SPF of 15 filters out approximately 94% of the UVB
rays whereas SPFof 30filters out 97% .
Theefficacy of aproduct is not only relatedtoits SPF
but also to its substantivity. The following three
labellingrecommendations toclarifysubstantivity:
protects up to 30 minutes of
continuous heavyperspiration.
protects up to 40 minutes of
continuous water exposure; and
protects for up to 80 minutes of
continuous water exposure
Sunscreen should be applied 30 minutes before sun
exposure with an adequate amount of sunscreen (2 mg/cm ) and to be
reappliedat 2to3hours interval.
Avoidmiddaysun
Seekshade
Wear protectiveclothingwithhighUPF(Ultraviolet ProtectionFactor)
Applyasunscreen
Solar Spectrumandits adverseeffects onSkin:
Indicationfor theuseof Sunscreens:
MeasuringandRatingEffectiveness of Sunscreen:
Sweat-resistant:
Water-resistant:
Waterproof:
Methodof Sunscreenapplication:
Four Messages for sunprotection:
[1]
[1]
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Reference- Rai R, Srinivas CR. Photoprotection. IndianJ Dermatol Venereol Leprol.
Indiais atropical country. Summer brings withit increasedheat
and humidity. This favours different types of fungal infections
of the skin. There are numerous medicine and topical
formulations (non-medicated) available in market for treating
fungal infections. But inmost of the cases patient suffers either
by prolongation of the disease course or by developing contact
dermatitis. Moreover when the patient consults a dermatologist the
morphology also is changed and this further delays treatment. So in this
section a brief overviewof fungal infections in summer and their treatment
is beinghighlighted.
The most common superficial fungal infections are dermatophytes and
pityriasis versicolor. The dermatophytic infections are termed commonly as
ringworm infections. They are named according to the body area affected
for example tinea capitis affects the scalp and tinea cruris- crural region.
They are aggravated by humidity, poor hygiene, overcrowding and even
poor immunity. Fomites help their transmission. Tinea infections start as a
papule or pustule and gradually
an annular scaly patch with
central clearance appears. The
border is usually studded with
pustules. It is associated with
itching. Tinea cruris also known
as jocker's itch. It may present like
tinea corporis or it may have
macerated areas in the groins.
The itching is severe. Athelete's
foot is tinea affecting the foot
specially the interdigital area.
Pityriasis versicolor is also common in summer. It presents as
hypopigmentedscalypatches over trunk, face.
Prevention-
Avoidsharingof clothes, towel, socks
Maintainproper hygiene
Frequent shampooingof hair toprevent tineacapitis
Tokeepflexural areas andwebspaces dry
a proper diagnosis can only lead to a proper treatment. In case
of confusionaskinscrapingcanbedonetofindthefungus.
clotrimazole, ketoconazole, sertaconazole,
terbinafine, cream/ lotion/ powder
fluconazole tablets 150 mg weekly can be given in adults. Oral
terbinafine, ketoconazole, itraconazole, griseofulvin are also available. But
the use of these agents should not be indiscriminate. A dermatological
opinion is always desired as it avoids the risk of misdiagnosis. Moreover this
unregulated use of antifungals is giving rise to drug resistance, specially to
terbinafin . Hence as a clinician we should use these antifungals judiciously
to prevent further drug ressistance. Moreover the unjustified use of topical
steroids indermatophyteinfections is alsonot desired.
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Treatment
Topical antifungals -
Systemic -
luliconazole
*
Reference - *Pranab K. Mukherjee, Steven D. Leidich, Nancy Isham, Ingrid Leitner,
Neil S. Ryder, and Mahmoud A. Ghannoum Antimicrob Agents Chemother. Jan 2003;
47(1): 8286.
1 1 1 2
2 1,
Fungal Infections in Summer
Dr. Joyeeta Chowdhury
MD (Dermatology, Venereology & Leprosy)
RMO-cum-Clinical Tutor, NRS Medical College & Hospital
Mob. No. 9433394924 Email : joyeeta_chowdhury@yahoo.co.in
Sunscreen
Dr. Ashim Kumar Mondal
M.B.B.S, MD (Skin), RMO cum Clinical Tutor,
Burdwan Medical College & Hospital
Mob. No. 09830866844 Email: dr.ashim10@gmail.com
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Annual Conference of Indian Society for Pediatric Dermatology
ISPD, Kolkata
14th, 15th & 16th November, 2014 Theme : Where Evidence Meets Experience
Venue : Hotel ITC Sonar, Kolkata
16A/1, Earl Street, Near Madox Square Park, Kolkata-700026
Email : ispd6kolkata@gmail.com Website : www.peddermindia.org
HFMD is often misdiagnosed as chicken pox, papular urticaria or viral
exanthema in early stage. HFMD is a viral illness characterized by acute
onset of appearance of papules and vesicles over distal extremities and
mouth. The most common etiological agent is Coxsackievirus A16 or
Enteroviru 71. In addition, sporadic cases with Coxsackievirus types A4-A7,
A9, A10, B1-B3 and B5 have been reported. Most of the cases are sporadic,
however epidemics occur regularly. HFMD is reported to be having
worldwide distribution. Many cases are known to occur in late summer and
early fall in temperate climates but throughout the year in tropical
countries. Most of the cases are children below10 yrs of age and there is no
sex predilection in most of the reports. However certain reports have
documented slight male predominance (male to female ratio being 1.2-
1.3:1). Infection is acquired by fecal-oral route or direct contact with oral
and skin lesions. Following entry virus multiplies in regional lymph nodes
and cause viremia. After that they reach target site and induce reticular
degeneration and local inflammation. This results in vesicle formation.
Soon, usually in 7 days, neutralizing antibodies appear and limits the
progression of disease. After an incubation period of 3-6 days, prodromal
symptoms (duration 12-36 hrs) are seen. Low grade fever (duration 2-3
days), malaise, anorexiaandmouthsoreness arecommonfindings.
Clinical feature is dominated by papules and vesicles involving oral mucosa
and skin (two-thirds of cases). Usually oral lesions appear as red macules
soon to progress to vesicles. These vesicles rupture easily and leave painful
superficial ulcers. Skin lesions are mostly limited to distal extremities
(dorsumof the hands andfeet as well as palms andsoles) andmouth, giving
the disease its name. In addition elbows, knees and buttock are involved.
Another characteristic feature is oval or elliptical vesicles surroundedby red
halo.
Diagnosis is based upon clinical findings. Characteristic shape of lesions and
siteof involvement areof paramount help. Theetiological diagnosis is made
by isolation of virus from vesicle fluid and stool. The disease is self limited.
Lesions heal completely in 3-7 days without any sequale. Counseling and
assurance and symptomatic treatment are required in most of the cases.
The most common complication is dehydration. It results from inadequate
intake of fluids because of painful ulcers. So monitoring of fluid intake and
output is useful.
Neurological complications of polio-like syndrome, aseptic meningitis,
Guillian-Barre syndrome, encephalitis, benign intracranial hypertension etc
are also reportted. Those may be fatal at times. These complications are
particularly associated with Enterovirus 71 infection- this highlights the
importance of etiological diagnosis. Such patients require hospitalization
and intensive supportive management. Vomiting, leukocytosis, fever of
more than 3 days, temperature >38.5 C and history of lethargy are risk
factors for serious complications in Enterovirus 71 infections. So in absence
of facilities for virus isolation, these clinical parameters can be of prognostic
significance.
It was academics at its best at the one day workshop hosted by
SIG-ACDR in collaboration with WB state branch at hotel, The
Sonnet, Kolkata on 6 April 2014, Sunday. The workshop was
attended by 50 delegates and has been accredited with 2 CME
points by WB medical council. The workshop comprehensively
covered the topic through 6 didactic lectures of half an hour
each followed by 2 panel discussion of one hour each on serious and non-
serious ADRs.
The day started with a short inaugural programme followed by the lighting
of inaugural lamp. Dr. Sudip das, Organizing secretary of the Workshop,
extended a cordial welcome to all the participants and Dr. Nilay Kanti Das,
Scientific chairperson, initiatedthescientific event.
Theprogramhighlights areas follows:
, Mumbai: ACDR: Anapproachtodiagnosis.
, Kolkata: Causalityassessment andreportingof ACDRs.
, Kolkata: Serious Cutaneous adverse reaction (SCAR)
Management guidelines
, KolkataSJS-TEN: Newer insights
, KolkataDruginducederythroderma(DIE)
, Udaipur Interesting ACDR from literature and clinical
practice.
There were also two panel discussion on SCAR &Non SCAR &a pre and post
test qustionnairefor theparticipants showedencouragingresults.
th
Dr Rajeshkumar
Dr Avijit Hazra
Dr. Sandipan Dhar
Dr. Manas Chatterjee
Dr. JoyeetaChowdhary
Dr. Lalit Gupta
MFMD 1 MFMD 2 MFMD 3
Hand Foot Mouth Disease
Dr. Avijit Mondal
MBBS, MD (Skin), RMO cum Clinical Tutor,
Burdwan Medical College & Hospital
Mob. No. 09830866844 Email: dr.ashim10@gmail.com
Adverse Cutaneous Drug Reaction
Dr. Nilay Kanti Das
Associate Professor,
Dept. of Dermatology, Medical College, Kolkata
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13th & 14th December, 2014
Venue : Confederation of Indian Industry (CII)
Suresh Neotia Centre of Excellence for Leadership,
(Behind City Centre - I)
DC - 36, Sector - I, Salt Lake City, Kolkata - 700064
Conference Secretariate
Dr. Sumit Sen
Organising Secretary, CUTICON WB 2014
IADVL WB State Branch
Moon Plaza, Flat - 2E, 62, Lenin Sarani, Kolkata - 700013
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Specialised Derma-Care-Centre for :
Skin, Nail, Hair & Allergy Treatment,
Hair Transplant, Dermaroller,
threading, Botox, Fillers,
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(Opp. Calcutta Technical School, Janbazar)
What is it?
idiopathic photosensitive
Whogets it? 3 decade female
What causes PMLE?
change in the amount of sun exposure
When does it occur?
What are the clinical features of PMLE?
papular
pruri ti c
How is PMLE diagnosed?
From which other conditions should it be differentiated?
Howtotreat PMLE?
Sunprotection:
Highpotent topical corticosteroids
Topical tacrolimus ointment
Antihistaminics
Short courseof systemic steroids inseverecases
Hydroxychloroquine
Phototherapy:
Severecases:
Polymorphous light eruption or PMLE as it is
commonly called, is an disorder.
The name 'polymorphic', or 'polymorphous' refers to the fact
that the rash can take many forms, although in one individual
it usuallylooks thesameeverytimeit appears.
PMLEcommonly manifests inthe of lifewith
preponderance.
Clearly sun is the primary etiologic factor for PMLE. A
is more critical than the absolute
amount of radiation. It is usually provoked not only by short wavelength
UVBbut alsobylonger wavelengthUVA.
PMLE mostly occurs in spring evoked by long hours of
exposure under the sun. If further sun exposure occurs, the rash settles by
itself without anysequela(hardeningeffect).
Clinically, the eruption may have
several different morphologies,
although in the individual patient
the morphology is usually constant.
The variety is the most
common, but papulovesicular,
eczematous, plaques and erythema
multiforme like lesions may also
occur. The lesions are extremely
. Someti mes burni ng
sensationmaybefelt.
Sun-exposed skin, especially that
normally covered in winter (eg,
upper chest, arms), is affectedprimarily, but autosensitizationmay leadtoa
generalizedinvolvement.
It can be diagnosed clinically by its morphology
and onset within hours of sunexposure. In few cases skin biopsy may be
required.
Lupus
erythematosus, photosensitivedrugeruption, contact dermatitis
Patient education regarding sunprotective measures is
very important. These include staying away fromsun during mid hours
of day, use of protective clothing, umbrellas and broad spectrum
sunscreens
UVAor UVB
Azathioprine, cyclosporine, thalidomide
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Polymorphous Light Eruption (Pmle)
Dr. Niharika Ranjan Lal
Senior Resident, Dermatology, ESI PGI MSR & Medical College, Joka
DISCLAIMER : The views and information expressed and provided in
the Articles are the views and information of the respective authors.
Skin Doctors Communique is not responsible for the authenticity of
the contents of the Articles and Skin Doctors Communique cannot be
held responsible or liable for any claim or damage arising out of any
actionor belief onthebasis of thecontentsof theArticles.
If faith in ourselves had been more extensively taught and practiced,
I am sure a very large portion of the evils and miseries that we have would
have vanished.
SWAMI VIVEKANANDA
Published by Dr. Asim Sarkar, Editor-in-Chief for SKINDOC 2014 at 30 S N Banerjee Road, Kolkata 700013. Printed by Modern Graphica, Kolkata 700 012. Ph. : 98318 51897
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Please write to :
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SKIN DOCTORS COMMUNIQUE
Allergology When, Why & Where
Dr. Naren Pandey
Allergist & Asthmologist & Specialist Immunotherapist
Belle Vue Clinic & Mediland
M : 9830062336 e-mail : pandeynaren@yahoo.com
Allergy is a very common ailment, affecting more than 20%of
the populations of most developed countries. The major
allergic diseases, allergic rhinitis, asthma, food allergies and
urticaria, are chronic, cause major disability, and are costly
bothtotheindividual andtotheir society. Despitetheobvious
importance of allergic diseases, in general allergy is poorly
taught inmedical schools andduring post-graduate medical education, and
many countries do not even recognize the specialties of Allergy or Allergy
and Clinical Immunology. As a consequence, many or most allergic patients
received less than optimal care from non-allergists. The World Allergy
Organization has recognized these needs and developed worldwide
guidelines defining what is an Allergist? , Requirements for Physician
Competencies in Allergy: key Clinical Competencies Appropriate for the
care of patients with Allergic or Immunologic Diseases , and
Recommendations for competency in Allergy Training for undergraduates
Qualifying as Medical Practitioners . These important position papers have
been published worldwide over the past few Years, but it is far too soon to
see whether they will influence the need for more, better and improved
traininginallergyworldwide.
Rhino-conjunctivitis, alongwithnonallergic rhinopathy.
Sinusitis, both acute and chronic, alone or complicated with nasal
polyps.
Otitis andEustachiantubedisorders.
Asthma and all its forms including cough-variant asthma and exercise-
inducedasthma
Coughfromall causes.
Bronchitis, chronic obstructive pulmonary disease (COPD) and
emphysema.
Hypersensitivitypneumonitis.
Alveolitis
Atopic dermatitis/eczema
Contract dermatitis
Urticariadndangioedema
Drugallergy
Foodallergy
Latex allergy
Insect allergy and stinging-
insect hypersensitivity
Gastrointestinal reactions resulting from allergy, including eosinophilic
esophagitis andgastroenteritis
Anaphylactic shock
Immunodeficencies, bothcongenital andacquired
Occupational allergic diseases
Identifying and managing risk factors for progression of allergic
diseases- the allergic march
Other specific organreactionresultingfromallergy
Conditions that maymimic or overlapwithallergic disease
An expert knowledge of the epidemiology and genetics of allergic
diseases immunodeficencies and autoimmune diseases, with special
knowledgeof regional andlocal allergens
Emollients
Antibiotics
Topical glucocorticosteroids
Immune modulators and other agents and techniques used to manage
eczemaandother allergic skindisorders
Use of immune modulators, such as specific allergen immunotherapy
(oral andinjective)
Immunoglobulin replacement used to treat allergic and immunologic
disorders
Monoclonal antibodies, includinganti-IgE.
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Allergologyinvolves thediagnosis andcareof patients with:
Allergists treat avarietyof skinconditions andareexpert intheuseof :
Part of thecurrent therapeutic arsenal includes :
References :
1. Del Giacco S, Rosenwasser LJ, Crisci CD, FrewAJ, Kaliner MA, Lee BW, et al. what is
anallergist?www.waojournal.org1:19-20,2008
2. kaliner MA, Del Giacco S, Crisci CD, Frew AJ, Liu G. Masparo J, et al, Requirements
for Physician Competencies in Allergy: Key Clinical Competencies Appropriate of
thecareof Patients withAllergic or Immunologic Diseases: APositionStatement of
theWorldAllergy Organization.
www.waojournal.org1:42-46,2008
3. Potter, PC, Warner, JO, Pawankar, RS, Kaliner, MA, Del Giacco. S. Rosenwasser, LJ, et
al, Recommendations for Competency in Allergy Training for Undergraduates
Qualifying as Medical Practitioners: A Position Paper of the World Allergy
Organization. www.waojournal.org2:150-154,2009.