Dermatology

Retraction: The measurement of serum tumor necrosis factor-alpha levels in patients with lichen planus Indian Journal of Dermatology 2019 64(3):165-165

Guidelines on management of atopic dermatitis in India: An evidence-based review and an expert consensus Murlidhar Rajagopalan, Abhishek De, Kiran Godse, DS Krupa Shankar, Vijay Zawar, Nidhi Sharma, Samipa Mukherjee, Aarti Sarda, Sandipan Dhar Indian Journal of Dermatology 2019 64(3):166-181 Background: Atopic dermatitis (AD) is a common and chronic, pruritic inflammatory skin condition that affects all age groups. There was a dearth of consensus document on AD for Indian practitioners. This article aims to provide an evidence-based consensus statement for the management of AD with a special reference to the Indian context. This guideline includes updated definition, etiological factors, classification, and management of atopic dermatitis. Methodology: The preparation of guidelines was done in multiple phases. Indian Dermatology Expert Board Members (DEBM), recommended by the Skin Allergy Society of India, prepared 26 evidence-based recommendations for AD. An extensive literature search was done in MEDLINE, Google scholar, Cochrane, and other resources. Articles published in the past 10 years were reviewed and recommendations were graded based on the quality of evidence as per GRADE. After forming the initial structure, DEBM met in Mumbai and gave their decisions on an agree and disagree scale with an Indian perspective. Finally, their suggestions were compiled for preparing the article. After DEBM finalized the draft, a treatment algorithm was formulated for the management of AD. Results: DEBM suggested a working definition for AD. The panel agreed that moisturizers should be used as mainstay of therapy and should be continued in all lines of therapy and in maintenance phase. Topical corticosteroids and topical calcineurin inhibitors should be considered as the first line of treatment. Among systemic therapies, cyclosporin should be considered first line, followed by azathioprine, methotrexate, and mycophenolate mofetil. Phototherapy can be an effecive alternative. Empirical food restriction was recommended against. Conclusion: These guidelines should form a reference for the management of patients with AD in an evidence-based manner.

Evaluation of HCP5 and Chemokine C receptor type 5 gene polymorphisms in Indian psoriatic patients Deepa Rajesh, Sudeep Nagraj, KS Praveen Kumar, A V Moideen Kutty, Sharath Balakrishna Indian Journal of Dermatology 2019 64(3):182-186 Background: Genetic variations associated with nonprogression of HIV infection to AIDS are enriched in psoriasis patients. HCP5 gene 335 T > G and chemokine C receptor type 5 (CCR5) gene Δ32 polymorphisms are associated with HIV nonprogression phenotype. Aim: The aim of this study was to determine the association of HCP5 gene 335 T > G (rs2395029) and CCR5 gene Δ32 (rs333) polymorphisms with psoriasis vulgaris (PV). Materials and Methods: Genotype of HCP5 gene 335 T > G and CCR5 gene Δ32 polymorphisms were determined by polymerase chain reaction (PCR)-restriction fragment length polymorphism and allele-specific PCR methods, respectively. Results: The frequency of HCP5 gene 335 T > G SNP was ~7 times higher in PV patients than in the control group (P = 1.49 × 10–8; odds ratio [OR] = 10.2; 0.95 confidence interval [CI]: 3.9–26.8). OR for the occurrence of HCP5 335 G allele in either homozygous or heterozygous genotype in PV patients was 13.1 (0.95 CI: 4.7–36.1). The strength of association was higher with moderate-to-severe subgroup (P = 3.29 × 10–9; OR = 18.4; 0.95 CI: 6.2–54.9) than with mild subgroup (P = 2.1 × 10–4; OR = 8.3; 0.95 CI: 2.6–23.3). In addition, the strength of association was higher with Type I (P = 9.53 × 10–8; OR = 15.3; 0.95 CI: 5.1–46.5) than with Type II subgroup (P = 6.8 × 10–6; OR = 11.0; 0.95 CI: 3.6–33.9). Type I gene Δ32 polymorphism was observed neither among psoriatic nor among healthy individuals. Conclusions: Our results indicate that HCP5 gene 335 T > G polymorphism and not CCR5 gene Δ32 polymorphism is associated with the increased risk of developing PV.

Investigation of immunovascular polymorphisms and intersections in psoriasis Buket Er Urganci, Ibrahim Acikbas, F Rezzan Er Indian Journal of Dermatology 2019 64(3):187-191 Background: Psoriasis is a chronic, inflammatory skin disease. The etiology of the disease is unknown. It is a polygenic and multifactorial disease, which interacts with genetic and environmental factors. Genetic factors (polymorphism/mutation) can alter the immune system and normal physiologically functioning keratinocytes to pathological or predisposition levels. Aims: We aimed to investigate psoriasis at a different and novel window by searching for vascular and immunological variations and intersections in psoriasis. We investigated the main vascular and hypoxic controlling factors, which are vascular endothelial growth factor (VEGF) and hypoxia inducible factor 1 alpha (HIF-1α), as well as immunological and serotonergic factors, such as TNF-α, IL-10, and 5HT2A, which could connect each other to the pathogenesis of psoriasis. Subjects and Methods: Nine single nucleotide polymorphisms (SNPs) in five genes were genotyped by mini-array format in 300 subjects: VEGF (rs2010963, rs833061, and rs1570360), HIF-1α (rs11549465), TNF-α (rs361525, rs1799964, and rs1800629), IL-10 (rs1800896), and 5HT2A (rs6311). Results: An association was found between rs1800629 (TNF-α) and Type I psoriasis, and rs833061 (VEGF) and Type II psoriasis. Haplotype analysis suggests that the coexistence of the polymorphisms rs1799964 (TNF-α), rs2010963 (VEGF), rs833061 (VEGF), and rs6311 (5HT2A) may be a protective factor for psoriasis. Conclusion: Our results suggest that the vascular component of the studied vasculo-immunologic variation is more relevant in the pathogenesis of psoriasis.

Peroxisome proliferator-activated receptor-γ gene polymorphism in psoriasis and its relation to obesity, metabolic syndrome, and narrowband ultraviolet B response: A case–control study in Egyptian patients Iman Seleit, Ola Ahmed Bakry, Eman Abd El Gayed, Mai Ghanem Indian Journal of Dermatology 2019 64(3):192-200 Background: Psoriasis is a common dermatologic disease with multifactorial etiology in which genetic factors play a major role. Peroxisome proliferator-activated receptor (PPAR)-γ is expressed in keratinocytes and is known to affect cell maturation and differentiation in addition to its role in inflammation. Aim: To study the association between PPAR-γ gene polymorphism and psoriasis vulgaris in Egyptian patients to explore if this polymorphism influenced disease risk or clinical presentation. Methods: Forty-five patients with psoriasis vulgaris and 45 age, sex and body mass index matched healthy volunteers who have no present, past or family history of psoriasis as a control group were enrolled. Selected cases included obese and nonobese participants. Detection of PPAR-γ gene polymorphism was done with restriction fragment length polymorphism polymerase chain reaction. Narrow-band ultraviolet B (NBUVB) was given for every case three times/week for 12 weeks. Results: Homopolymorphism, heteropolymorphism, and Ala allele were significantly associated with cases (P = 0.01, P = 0.01, and P = 0.004, respectively) and increased risk of occurrence of psoriasis by 5.25, 3.65, and 3.37 folds, respectively. Heteropolymorphism was significantly associated with nonobese cases compared to obese ones (P = 0.01). Ala allele was significantly associated with obese cases (P = 0.001) and increased risk of occurrence of psoriasis in obese participants by 1.14 folds. Homopolymorphism, heteropolymorphism, and Ala allele were more prevalent among obese cases without metabolic syndrome (MS) than obese cases with MS but without statistical significance. Percentage of decrease of mean Psoriasis Area and Severity Index score before and after 3 months of treatment with NBUVB was higher in cases with heteropolymorphism with no significant difference between homo- and heteropolymorphism. Conclusion: PPAR-γ gene polymorphism is associated with and increased the risk of psoriasis and its associated obesity in Egyptian patients. It has no role in NBUVB response in those patients. Future large-scale studies on different populations are recommended.

Advanced glycation end products, a potential link between psoriasis and cardiovascular disease: A case–control study Tulin Ergun, Vildan Yazici, Dilek Yavuz, Dilek Seckin-Gencosmanoglu, Gulsen Ozen, Andac Salman, Haner Direskeneli, Nevsun Inanc Indian Journal of Dermatology 2019 64(3):201-206 Context: Advanced glycation end products (AGEs) promote oxidative stress and inflammation by altering structure and function of proteins. They are excessively produced mainly in hyperglycemia, chronic inflammation and are involved in the development of atherosclerosis and cardiovascular disease. Aims: The aim of this study was to investigate whether skin AGEs levels were increased and had relation to premature atherosclerosis in patients with psoriasis. Subjects and Methods: Fifty-two psoriasis patients and 20 healthy controls (HC) were included. AGEs were determined by skin autofluorescence (SAF) analysis. High-sensitive C-reactive protein (hsCRP) and carotid intima-media thickness (CIMT) were also investigated. Physical activity and dietary patterns were determined. Statistical Analysis Used: Fisher's exact test, two-sample t-tests, Mann–Whitney-U test, Pearson correlation, Spearman correlation, and Wilcoxon test. Results: SAFs were increased in psoriasis patients (1.8 arbitrary units [AUs]) compared to that in HC (1.6 AUs) (P = 0.057). Median CIMT values of HC and psoriasis groups were 0.43 (0.28–0.79), and 0.59 (0.44–0.98) respectively and the differences were significant (P = 0.001); hsCRP levels were not different between groups. Conclusions: Skin AGE accumulation was found to have a correlation with CIMT in psoriasis patients providing evidence for the role of AGEs in premature atherosclerosis.

Evaluation of serum adenosine deaminase and inflammatory markers in psoriatic patients Yousry M Moustafa, Moustafa Ahmed Elsaied, Ehsan M Abd-Elaaty, Rasha A Elsayed Indian Journal of Dermatology 2019 64(3):207-212 Background: Adenosine deaminase (ADA) is an enzyme involved in purine metabolism and it is a marker of nonspecific T-cell activation. Few studies have shown high levels of ADA in the epidermis and sera of psoriatic patients. Other inflammatory markers such as high-sensitive C-reactive protein (hsCRP), erythrocyte sedimentation rate (ESR), and serum uric acid (SUA) have shown correlations with psoriasis area severity index (PASI) score. The correlation between ADA and PASI score is still a matter of debate. Aims: The aim of this study was to evaluate serum ADA, hsCRP, SUA, and ESR in psoriatic patients and their correlation with PASI score. Patients and Methods: This study included 60 psoriatic patients divided according to PASI score into three groups (mild, moderate, and severe) each containing 20 patients. PASI score <10 was defined as mild, (10–20) moderate, and >20 severe. Twenty healthy subjects of matched age and sex were included as control. Serum ADA, hsCRP, SUA, and ESR were evaluated for patients and controls. Correlations of ADA, hsCRP, SUA, and ESR with PASI scores were done. Results: While ADA, hsCRP, SUA, and ESR showed a significant increase in psoriatic patients compared with that of the controls (P<001), they showed no significant difference between different psoriatic groups (P>0.05) and no correlations with PASI score (P>0.05). The frequency of joint affection increased with increasing severity of psoriasis (5%, 10%, and 25% in mild, moderate, and severe psoriasis, respectively). Conclusion: Serum ADA, hsCRP, SUA, and ESR showed higher levels among psoriatic patients than in controls. The increased ADA in psoriatic patients supports the role of T-cell activation and proliferative disorder in the pathogenesis of psoriasis. No significant correlations were found between these biomarkers and PASI score. Further studies are needed to validate these biomarkers as diagnostic and prognostic factors in psoriasis.

Fixed tapering dosage of acitretin in patients with psoriasis: A short-term analysis of clinical efficacy and its effects on biochemical parameters Varadraj V Pai, Diksha Phadke, Pankaj Shukla, Krupeksha Naik Indian Journal of Dermatology 2019 64(3):213-216 Background: Acitretin is a widely used systemic retinoid in the treatment of psoriasis. Dosage of acitretin in not weight adjusted due to certain interindividual variations. Objective: To evaluate the clinical efficacy and effects on biochemical parameters of fixed tapering dosage of acitretin in patients with psoriasis administered over a period of 4 weeks. Materials and Methods: This was an observational study. The study included patients of psoriasis vulgaris in the age group of 18 and 65 years with a psoriasis area severity index (PASI) score of >10 which was not responsive to topical therapy and phototherapy. Patients were given oral acitretin daily at a dose of 25 mg BD for 2 weeks, which was later tapered to 25 mg OD for another 2 weeks. The clinical efficacy and biochemical parameters were assessed. Results: Out of the 18 patients, PASI 75 was achieved in 66% of the patients by the end of the third week. Significant elevations were noted in serum lipids during 4 weeks, which returned to normal limits or near baseline levels at the end of 4 weeks. Conclusion: Fixed tapering dose of acitretin is effective in psoriasis with minimal clinical and biochemical adverse events

Phakomatosis pigmentovascularis: A clinical profile of 11 Indian patients Abhijit Dutta, Sudip Kumar Ghosh, Debabrata Bandyopadhyay, Dibyendu Bikash Bhanja, Surajit Kumar Biswas Indian Journal of Dermatology 2019 64(3):217-223 Introduction: Phakomatosis pigmentovascularis (PPV) is a rare congenital syndrome characterized by the simultaneous presence of capillary malformation and pigmentary nevi. The objective of our study was to describe the clinical characteristics of a series of Indian patients presenting with this rare entity. Materials and Methods: It was a record-based descriptive case series. Results: A total of 11 patients with PPV (9 females, 2 males, age range: 7 days to 45 years; mean 11.6 years) were studied. Port wine stain was present in 10 (91%) patients and one patient (9%) had cutis marmorata telangiectatica congenita. Isolated nevi of Ota and Mongolian spots were seen in 4 (36%) patients each. Simultaneous presence of both Mongolian spots and nevus of Ota was present in 1 (9%) patient. The combination of Mongolian spots and bilateral palatal hyper-melanosis was noticed in 2 (18%) patients. Café au lait macule was present in one patient. Bilateral ocular melanosis was found in 3 (27%) patients. Unilateral ocular melanosis was noticed in 4 (36%) patients. Two patients (18%) had history of seizure disorder and intracranial vascular anomalies on MRI imaging. Two patients (18%) had features of Klippel-Trenaunay syndrome. According to the traditional classification, three patients had PPV type 2b, one patient had PPV type 5b, and seven patients had PPV type 2a. According to the Happle's classification, 10 patients had PPV of cesio flammea type, and one patient had PPV of cesio marmorata type. Limitations: We could not perform genetic study of the patients. Conclusion: Our findings emphasize the importance of detailed systemic evaluation including ocular examination and brain imaging in every patient of PPV.

Abnormal serum copper and zinc levels in patients with psoriasis: A meta-analysis Li Lei, Juan Su, Junchen Chen, Wangqing Chen, Xiang Chen, Cong Peng Indian Journal of Dermatology 2019 64(3):224-230 Background: Copper and zinc are important trace elements involved in the development of psoriasis. However, reports regarding changes in serum copper and zinc levels in patients with psoriasis have been inconsistent. Aims: This meta-analysis was designed to analyze changes in serum copper and zinc levels between patients with psoriasis and a healthy population. Materials and Methods: English and Chinese literature from international and national electronic databases from 1988 to May 2016 was analyzed. Studies that performed a comparative analysis of serum copper and zinc levels between patients with psoriasis and healthy controls were included in the meta-analysis. The random-effects model was used to calculate the overall combined estimates of serum copper and zinc levels between patients with psoriasis and healthy individuals. Results: Fifteen references were included in this study, including 1324 patients with psoriasis and 1324 healthy controls. Compared with healthy controls, serum copper levels were significantly increased (Z = 4.02, P < 0.0001; standardized mean difference [SMD], 1.23; 95% confidence interval [CI], 0.63 to 1.82), and serum zinc levels were significantly decreased (Z = 2.95, P < 0.0001; SMD, −1.35; 95% CI, −2.25 to − 0.45) in patients with psoriasis. Conclusions: In conclusion, increased serum copper and decreased serum zinc levels were generally observed in patients with psoriasis. Treatments to normalize the serum copper and zinc levels may improve the outcome of psoriasis patients.

Alexandros Sfakianakis
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