Authors : Dr Brijesh Nair .

INTRODUCTION

Dermatology is a fascinating and emerging speciality with burgeoning possibilities. It is a speciality in flux, what with the arrival of aesthetic dermatology, dermatosurgery, hair transplant surgery including flaps and grafts, dermoscopy, venereology, leprology and of course, the big daddy of them all ‘Clinical Dermatology’ . There are lots of therapeutic, clinical and diagnostic pearls with firm roots in evidence based medicine. But dermatology is enriched by what went on before us : the wealth of experiential dermatology as opposed to evidence based modern dermatology. I intend this column to be a ‘cocktail’ of experiential & the experimental! So here goes.

1. The action of Metformin in Polycystic Ovarian disease and insulin resistance and as an adjuvant in associated acne/acanthosis nigricans and is well known (Indian J Pharmacol. 2016 Jan-Feb;48(1):4-10). The history of metformin dates back to the usage of the herb Galega officinalis. This herb was found to be rich in a substance called guanidine with blood-glucose-lowering properties, which later was discovered to be the chemical basis of metformin.

What is noticed is that acne is associated with subclinical insulin resistance in many cases where associated features of acanthosis nigricans and biochemical hyperandrogenism are absent. Increased levels of IGF-1 have been demonstrated in both males and females with acne. IGF-1 is strongly expressed in sebocytes and suprabasal cells of the sebaceous ducts with IGF-R being avidly expressed in all regions of sebaceous glands(Br J Dermatol. 2008 Sep; 159(4):990-1).

An addition of sustained release metformin 500 mg (to avoid GI side effects, start at low doses) and increasing to 500 mg BD (Max – 2 gm/d) is effective as an adjuvant to retinoids in isotretinoin resistant inflammatory acne in lean patients without clinical and biochemical addenda of hyperandrogenism.

2. Bleach baths are off late coming into prominence particularly in light of the role of Methicillin resistant staphylococcus aureus(MRSA) colonisation and its role in atopic eczema. It reduces MRSA carriage and thereby alleviates atopic eczema and can be offered in severe atopy in children, which can be a major cause of concern for caring parents. The steps involved are :

• Start by using lukewarm water to fill a tub for a normal bath. Move any valuable clothing or linens away from the bathtub to avoid permanent whitish discoloration.


• Add ½ cup (approx. 90-100 ml) of common household liquid bleach (sodium hypochlorite 6%, such as Clorox) to the bath water, and swirl to mix. This should create a solution of diluted bleach just a little bit stronger than chlorinated swimming pool water.


• If you use a smaller amount of water, you must cut down on how much bleach is added. For example, if you fill the tub only half way to the overflow drain, use about 1/3 cup of bleach. For a 20 litre container of water, use only 1 tablespoon of bleach.


• Soak in the chlorinated water for about 15 minutes.


• Thoroughly rinse the skin with lukewarm, fresh water at the end of the bleach bath.


• As soon as you’re finished rinsing off, pat with toweling or shake off the water droplets like a puppy. Do not rub the skin dry, as this will aggravate the itching.


• Immediately, while the skin is still damp, apply any prescribed medication cream or ointment to the inflamed areas, then a moisturizing cream (petrolatum jelly/cetaphil moisturizing cream) overall. It is important to seal the moisture in the skin, so don’t wait until the skin has dried out completely.


• Bleach baths can be taken daily as part of the treatment for Staph or MRSA infections, or 2-3 times per week as part of treatment for eczema.


• Do not use undiluted bleach directly on the skin. Protect against the bleach splashing directly into the eyes. Do not use bleach baths if there are many breaks or open areas in the skin, as this will cause intense stinging and burning. Do not use bleach baths for patients with a known extreme sensitivity to chlorine.

3. Glossopyrosis ( or burning tongue ) can often be a frustrating condition to treat for dermatologists, physicians and dentists. B complex vitamins are prescribed rampantly for this symptom which can be multifactorial. What is less known is that drugs taken for other indications can cause this symptom. Some of the drugs reported to cause glossopyrosis are:

Buspirone, Captopril, Enalapril, Levodopa. There are certain drugs which cause glossodynia (painful tongue often merges with burning) are: Amoxicillin, Buspirone, Carbenicillin, Cloxacillin, Clozapine, Erythromycin, Fluoxetine, Griseofulvin, Imipramine, Lithium, Methyldopa, Rifampicin, Sumatriptan, Ticarcillin, Triazolam, Trihexyphenidyl, etc. So enquire about temporality of disease symptom and initiation of therapy with any of these or other agents initiated for any indication to patients suffering from this symptom. And you as the identifier of the culprit can derive satisfaction.

4. Granuloma annulare is a necrobiotic dermatological condition which is associated with diabetes but can be seen in non diabetic individuals also. Sometimes, fortuitous remission is obtained when a biopsy/trauma/intralesional saline injection is applied to one of the lesions and all lesions vanish by the process of reverse Koebnerisation. However, many a times the patient and doctor are not so lucky and the intralesional steroids cannot be repeated as it is painfully invasive.

Hence non invasive options are always welcome. Generalized granuloma annulare (GGA), can be observed in 15% of affected patients. In these exigencies, disease can be treated with single dose of rifampicin 600 mg, ofloxacin 400 mg, and minocycline 100 mg (ROM) given once a month for 6 months. This leads to long term remissions and occasionally cure. The treatment is simple, cost effective and non-invasive (Indian J Dermatol. 2013 May-Jun; 58(3): 197–199.). Another therapy option is Allopurinol which is given in 300 mg bid dosage for 6 to 8 months and generally takes 2 months till lesional resolution (Dermatologic Therapy, Vol. 23, 2010, S24–S27).