solid newletter sept-2015 final · qintradermal test qin vitro test rast / ltt ... diabetes,...

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Board Members President: Dr.S. Shobana MD, DD Secretary: Dr. Samna Pramod, DDVL Advisory Board Dr. D. Prabhavathy MD, DD Dr. K. N. Sarveshwari MD, DD, DNB Dr. Maya Vedamurthy MD, DD Dr. Parvathi Padmanabhan MD, DD Executive Board Dr. T.K. Anandi MD Dr. Lakshmi DDVL Dr. Divya DDVL September 2015 Editorial Board Dr. Shwetha Rahul M.D.DVL Dr. S. Varalakshmi DDVL Dr. Sindhuja M.D.DVL Society of Ladies in Dermatology Society of Ladies in Dermatology is an initiative to bring together lady dermatologists to further academic interactions among our peers. L I O D S Connect September 2015

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Board Members

President:

Dr.S. Shobana MD, DD

Secretary:

Dr. Samna Pramod, DDVL

Advisory Board

Dr. D. Prabhavathy MD, DD

Dr. K. N. Sarveshwari MD, DD, DNB

Dr. Maya Vedamurthy MD, DD

Dr. Parvathi Padmanabhan MD, DD

Executive Board

Dr. T.K. Anandi MD

Dr. Lakshmi DDVL

Dr. Divya DDVL

September 2015

Editorial Board

Dr. Shwetha Rahul M.D.DVL

Dr. S. Varalakshmi DDVL

Dr. Sindhuja M.D.DVL

Society of Ladies in DermatologySociety of Ladies in Dermatology“ ”is an initiative to bring together lady dermatologists to further academic interactions among our peers.

L IO D

S

ConnectConnectSeptember 2015

Mother Teresa's birth date fell on August 26. Besides her exemplary contribution to society, her powerful yet simple statements are guidelines for us to think and live well. After all, the thought translates into words and actions.

"If you judge people, you will have no time to love them"

We often are quick to judge our colleagues and pass derogatory comments on their unethical (in our opinion!) practices . We forget that others may likely be judging us as well, by their standards. But why love them? We can ignore them of course. A negative judgement or comment has its seed in our thought, and pollutes it right away, and words or actions that follow further breed an unhealthy personality. So, first for a selfish reason, we should be non judgemental, especially when our words have no impact on the recipient whatsoever! A mature person can actually develop positive feelings of love, if he stops judging people.

Judging takes a toll on personal relationships also. Friendships survive decades and flourish because we do not judge our friends.

Let us learn to love !

SOLID - Sept-15

Editor’s Note:

President’s Message:

Dear Members of SOLID,

Seasons greeting from all of us at the helm of SOLID.

It was a great pleasure to meet all of you at the last meeting where we had a good interaction withDr. Shruthi who gave us insight into the management of PCOS. Dr Sentamilselvi and Dr Varalakshmi discussed various topics of common interest and gave snippets of information from various conferences held around the globe.

Ladies we are gearing up to celebrate our 2nd anniversary in December 2015 !!

There will be a workshop held in November where a number of skillsets will be taught by experts to postgraduates in dermatology a part of the technical training programme. Didactic lectures will be held by eminent persons on topics of their expertise as part of the anniversary programme. The annual quiz for post-graduates will also be held on that day. So, we are looking forward to enthusiastic participation from all our members to make this event a grand success.

Long Live SOLID !!

SOLID - Sept-15

The 6th solid meeting started with an energizing and informative talk by Dr. Sruti Chandrasekaran AB (Int Med) AB (Endo) about Polycystic Ovarian Syndrome (dermatological Approach).

She started the talk with various cases 0f PCOS and about the incidence, pathophysiology,clinical manifestations, diagnosis and treatment.

PCOS is a syndrome characterised by the triad of Menstrual irregularities, Hyperandrogenic state and Metabolic problems. It is the number one endocrinopathy in reproductive age group.It is described in 1935 by Stein and Leventhal . The incidence is 10 to 20% in Indian women and there is a strong genetic component in first degree relatives.

Insulin resistance is the key factor in the pathogenesis of PCOD and it involves multiple specialities like Gynaecology, Endocrinology, and Dermatology.PCOD is a diagnosis of exclusion. It is not a scan diagnosis as polycystic morphology is very common (40 % finding).

Clinical manifestations of PCOS :

Gynaecological - Menstrual Distrubances - Oligomenorrhoea- amenorrhoea- infertility

Regular cycles are present in 30%

Dermatological : *Hirsutism*Acne*Acanthosis Nigricans*Female pattern hair loss

Informative talk by Dr. Sruti Chandrasekaranabout Polycystic Ovarian Syndrome (dermatological Approach)

SOLID - Sept-15Metabolic :

~Obesity~Insulin resistance

Asymptomatic – 20%

Investigations

75g OGTT (Mandatory) Tests that are done as neededLFT * LH/FSHThyroid function * ProlactinDHEAS * Cushing’s screenTotal testosterone * Growth Hormone excess17 OH Progesterone * Ultrasound of Pelvis

ManagementWeight loss is the key treatment for PCOS as it

* restores ovulation and fertility* corrects hyperinsulinism* improves lipid and androgen profiles

OCP

Reduce testosterone production, stimulates SHBG and inhibits conversion of free testosterone to DHT

• Non-androgenic progestogens – Desogestrol 0.15mg +EE 30mcgDesogestrol 0.15mg +EE 20mcg

• Anti androgens with progestational activityCyproterone acetate (EE 30mcg + C 2mg) : DianeDrosperinone (EE 30mcg + D 3mg) : Yasmin

Norgestrel and Levonorgestrel to be avoided as they increase hirsutism.

There are useful for both Hirsutism and uncontrolled Acne in PCOS . OCPs to be taken for 3 to 6 months to see any improvement.

Systemic therapiesAnti androgens : 1.spironolactone

2.Finasteride3.Flutamide

Gnrh analogueGlucocorticoids Metformin

• 500-2500mg/day can be used• Helps with weight loss• Helps the menstrual cycle • Controls metabolic problems• Improve fertility rate if combine with clomiphene

Long term management • Plus ongoing surveillance • Regular ,possibly annual GTT recommended in women with PCOS• Patient to be managed for impaired glucose tolerance, endometrial hyperplasia,

hyperlipidemia,metabolic syndrome and cardiovascular health.

SOLID - Sept-15

Conference Compendium by Dr. Sentamilselvi and Dr. S. Varalakshmi

I. DAAS SUMMIT : 3-5th July 2015

1.Management of hair loss in patients who do not wish to take finasteride: Some options. May

not have real evidence

lSaw Palmetto - very few studies to verify the efficacy. Dose required is 160mg twice a day

lKetoconazole Shampoo - decreases perifollicular inflammation and takes care of

seborrheic dermatitis

lAminexil -decreases perifollicular fibrosis

lLow level light therapy

lGrowth factors, PRP, Mesotherapy

lBiochanin A + Acetyl Tetra peptide

2.Varicella in Pregnancy:

lMaternal varicella (8–12 weeks) - risk of congenital varicella syndrome.

lTreatment - Acyclovir 800mg 5 times a day for 7 days.

l Intravenous acyclovir 10- 15 mg/kg - for severe complications in pregnancy.

lVaricella immunization is recommended for all non immune women (no H/o documented

varicella/seronegative).

l In Pre-pregnancy - Women should receive the chicken pox vaccine at least 30 days before

becoming pregnant.

lPost-pregnancy - The immunization consists of 2 doses amonth apart.

lWithin 96 hours of exposure passive antibody prophylaxis with VZV immunoglobulin G is

indicated.

3.Difficult to control psoriasis:

lPsoriasis with HIV/Hepatitis B/Hepatitis C

lPhototherapy is a safe option (BB–UVB,NB-UVB & PUVA therapy).

lAcitretin – of particular value in patients with known infection, active malignancy or HIV

because of the lack of associated immunosupression and little cumulative toxicity even

after use for extended periods of time.

lChronic carriers of Hepatitis B should not be treated with Biologics because of the risk of

reactivation. Patients with Hepatitis C/HIV should be appropriately evaluated and

monitored during therapy with biologics.

4.Psoriasis in Pregnancy and Lacatation

SOLID - Sept-15lPhototherapy - Both NB-UVB and BB-UVB are safe in pregnancy

lCyclosporine and Corticisteroids - relatively safe

lTNF alpha inhibitors such as adalimumab, eternacept and infliximab - cautiously used

in pregnancy (FDA Category B)

lAcitretin & Methotrexate - contraindicated in pregnancy

lInfliximab - safe in lactation.

lEtanercept - minimally excreted in breast milk but systemic absorption is unlikely.

II. Excerpts from WCD 2015

1. Drug Reaction

nLiver toxicity – number one reason for drug withdrawal

nHigh risk drugs - methotrexate and ketoconazole.

nIf drug reaction (Liver) - occurs after 90 days of a drug administration think of addition of

alcohol, viral hepatitis, additional drug or non-alcoholic steatohepatosis.

nPercutaneous liver biopsy is still gold standard.

nP3P is not easily available.

n Transient elastography or Fibroscan is latest successful technology.

nTreatment for EGFR inhibitor drug rash - topical steroids with clindamycin, Oral Doxy

and Isotretinoin.

nHand foot syndrome- topical keratolytics like urea, salicylic acid and clobetasol with

salicylic acid.

nAntimicrobial peptides- Protect against infection.

III. CME on Cutaneous ADR, Powai on 10th May 2015

nIncidence of Cutaneous Adverse drug reaction is 2 to 30%

n3-8% of hospital admissions

n5 to 15% of drug courses

n2% CADR are serious

n0.1 - 0.3% can be fatal

nMost go unreported

nThe cutaneous drug reactions can be

nSimple - where there is no internal involvement

nComplex - where there is additional systemic involvement.

nAlso classified as

nImmunological

nNon Immunological.

nPatient is on more than 6 drugs- drug reaction chances - less than 5 %

nPatient is on more than 15 drugs - drug reaction chances - more than 40%.

SOLID - Sept-15nIncrease the chances of a drug reaction- decrease immune status

nolder age, boys less than 3 years and girls more than 9 years.

nThe problems with a drug reaction are

nCan develop with any drug at any time.

nLack of predictability and reproducibility.

nReactions can also develop after stopping the drug.

nLong latency between the administration of the drug and development of a drug reaction.

nThere can be paradoxical reactions

The skin reactions and its relation to time

nMinutes to hours

tUrticaria/ angioedema/anaphylaxis/ red man syndrome

nWithin days to weeks

tFixed drug eruption, steven johnson syndrome,Acute generalised exanthemaous

reaction, exanthematous rash

nWithin months

tDRESS/ DHS

nWithin years

tLichenoid drug reaction

nSulphonamides, antibiotics, NSAIDs, anti epileptics, allopurinol, antihypertenstive,

antimalarials are responsible for > 75% of cutaneous adverse drug reactions.

Art and science of diagnosing cutaneous adverse drug reactions Establish:

qHistory of exposure to drug

qRelationship with intiation of drug

qRelationship with withdrawal of drug

qTest dosing

qPatch testing

qIntradermal test

qIn vitro test RAST / LTT

Techniques to identify the causative drug

rIntradermal tests

rRAST for drug specific IgE

rBasophil degrnulation test

rHistamine Release Assay

rpassive heamaggulitination

rpatch tests

rlymphocyte transformation test

rlymphocyte toxicity assay

rflow cytometry

rcytokine assays

SOLID - Sept-15Drug rechallenge. How to do it?

uExplain the need to the patient.

uAdmit the patient, seek informed written consent.

uBe prepared to treat a positive reaction.

uTest safer drugs first.

uOral administration of one drug a day.

uDose depends upon the severity of the reaction.

uConfirm reaction and then treat it.

Which are the drugs to be challenged when the causative drug is unknown?

mCiprofloxacin, amoxicillin, cefadroxil, doxycycline, metronidazole, albendazole,

chloroquine, fluconazole, etoricoxib, paracetamol, nimesulide, diclofenac, ibuprofen,

iron -B complex

mDrug induced paronychia is caused by - retinoids, methotrexate, cyclosporin,

indinavir,Taxanes, EGFR blockers. relapse is a rule with surgical excision

mDrug induced gyneacomastia caused by spirinolactone, finasteride, antiandrogens,

ketoconazole, CCBs, ART drugs - PIs and NNRTIs

mRed man syndrome is caused by Infliximab, teicoplanins, cefepime, amphotericin B

IV. AAAD 2015

vThe most common problem dermatologists deal with is itch.

vNot all itches are equal. There are different types of itch, and addressing them also has to

be different.

vOne presentation that intrigued many dermatologists was by a leading hepatic

researcher, Andreas Kremer, MD, who presented “Cholestatic Itch: Basic Mechanisms

and Clinical Management.” Dr. Kremer is from Friedrich-Alexander University of

Erlangen, Nuremberg, Germany.

v‘Chronic Pruritus: Bedside to Bench Perspectives’ drew a large, attentive audience on

March 21.

vScalp Itch

oScalp itch is common in elderly, peripheral neuropathy, Diabetes, postherpetic

neuralgia.

vScalp itch - is associated with trichotillomania, depression and stress

vTherapies include

oseveral nonsteroidal topical medications

osystemic treatments such as gabapentin

oeven a holistic approach using acupuncture.