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