Recent Advances in Dermatology Sanjay Ghosh, Dinesh Hawelia, Susmit Haldar
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1Recent Advances in DERMATOLOGY2

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As medicine is an everyday-changing science with newer researches and refined clinical experiences, and, also in view of the possibility of human error, neither the editors nor the authors nor the publisher warrant that the information contained in the book is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information presented in this work.
3Recent Advances in DERMATOLOGY
Editor-in-Chief Sanjay Ghosh Consultant Dermatologist AMRI-Apollo Hospital Kolkata Associate Editors Dinesh Hawelia Consultant Dermatologist Suraksha Hospital Kolkata Susmit Haldar Consultant Dermatologist Calcutta Skin Institute Kolkata
4Published by
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Recent Advances in Dermatology
© 2004, Sanjay Ghosh
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the Editor-in-Chief and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and Editor-in-Chief will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition : 2004
9788180613067
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5
To
all the past dermatologists of India,
whose footprints are showing
path in our derma-trek
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7Contributors 9Foreword
The science of dermatology is rapidly advancing and it is essential for every practitioner to keep abreast of the latest advances in the subject. With the advent of Information Technology, medical information is rapidly dissipated with just the click of a button. However, with volumes of information that is available, one has to weed out well-researched information and the practicability of this information in everyday practice. It is very difficult for a busy practitioner to scan through and refer to the enormous amount of literature that is available. With this in mind, the editors have computed advances in various aspects of dermatology that have been authored by well-known dermatologists in the field. This update discusses many subjects of current interests.
Narrowband UV-B light is a new modality for treating vitiligo. It is gaining popularity as this is safe and does not require any systemic medication. These aspects have made this form of therapy as a treatment of choice for children in vitiligo.
Computers and digital photography are absolute “Must know” for all dermatologists. The Internet is a goldmine of information waiting to be tapped, and also a means of sharing information as computers connect you easily and fast to your areas of interest. Digital photography as well facilitates pictorial record of interesting cases and of the effect of therapy.
The update also includes subjects of contemporary interest as apoptosis and cell markers in dermatology. Scleroderma and leukocytoclastic vasculitis have always been enigmatic problems that have been aptly updated.
Other subjects of interest are emergencies in pediatric dermatology, recently introduced systemic and topical drugs in dermatology as well as drug eruptions to new systemic agents.
This book of recent updates in dermatology covers a wide variety of topics and would be of immense interest and utility to the consultant dermatologist in practice as well as students of dermatology.
Dr. Rui Fernandez
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11Preface
“Who can utter the last words of one which has no end?”
—Rabindranath Tagore
I felt somewhat hesitant to accept the proposal given by Jaypee Brothers, the reputed medical publisher of New Delhi to become the Editor-in-Chief of such a volume under the title ‘Recent Advances in Dermatology’. The underlying reason was nothing but that it seemed to me a very difficult task to get writings from the busy dermatologists, who can perform this only by stealing time from their hectic academic, hospital or practising schedules. However, later, my fear-complex got completely erased when I received prompt response from most of them whom we approached, including some of the senior and eminent dermatologists of the country. I hereby convey my deepest regards to all the authors and co-authors for their sincere co-operation with this project.
This book was designed as an academic project with the target readers as both postgraduate students and practising dermatologists; we, therefore, desired that the chapters would encompass glimpses of existing knowledge in the light of recent advances in the field. So, we invited articles from dermatologists staying at different parts of the country, both seniors for their retrospective analysis with vast experience and comparatively younger for their enthusiastic and prospective views on the subjects. I sincerely apologize to those numerous academic dermatologists of the country who could be the eligible contributory authors of this collection but have not been included due to the dearth of space. However, we firmly believe that we would be able to include them in rotation in the subsequent editions of this title.
I also acknowledge my heartfelt respect to Dr. R. Fernandez and Dr. B. Haldar as they kindly agreed to write the ‘Foreword’ and ‘Introduction’ respectively for this volume.
I must thank and pay regards especially to Mr Tarun Duneja, General Manager (Publishing), Jaypee Brothers for his constant help and co-operation in this project. At the same time, I give my personal thanks and regards to all the staff of Jaypee Brothers, both New Delhi and Kolkata Branch. My offer of earnest regards should not have an end without giving this to Mr. Subhrajyoti Bose, who on behalf of me, has taken the burden of painstaking job of DTP and all other computer works of this issue. Last but not the least, no language can express my gratefulness to my associate editors who have walked beside me constantly from the beginning to the end of the present journey.
Sanjay Ghosh
12Introduction Clinical Dermatology: Its Past, Present and Future
B Haldar
Diagnosis and treatment for the community are the two watch-words of every branch of medicine, be it dermatology or any other speciality. Admittedly, there has been a phenomenal development in medicine over the past two decades or so. ‘Even though we can now comprehend many skin disorders at a molecular level and have advanced our therapeutic realm to include laser technology and immunobiology, the cornerstone of all dermatological endeavours will always be a careful clinical observation.’ While for professional safeguard ‘evidence-based medicine’ has been a crying need of the day, the importance of clinical dermatology can neither be underestimated nor ignored. If we look at the history of growth and development of medicine in totality, along with the benefits the community had obtained thereby, the role played by clinical medicine had been of vital importance. It would indeed constitute a great danger to the wider community if ‘evidence-based diagnosis’ outweighs the ‘clinical’ one where the diagnosis is written large on the face. One should not forget that the base of diagnosis is essentially clinical and that it is the clinical findings that dictate the necessary tests to confirm or reject the diagnosis.
There is also another aspect that cannot be dispensed with outright. Community is a complex structure, the complexity varying from country to country—over-rich, rich and utterly poverty-stricken; over-developed, developed and under-developed. High-skilled investigative facilities are neither uniformly available everywhere nor every community can afford to bear the cost thereof. These are naked truths that can hardly be brushed aside. Cost-benefit analysis is, therefore, equally pertinent.
Some instances may enlighten the matter. For treating scabies, the demonstration of Sarcoptes scabiei or eggs from the burrows is seldom, if at all, done in India in spite of the fact that it is considered as a 13pathognomonic sign. Similarly, in pure neuritic leprosy, the finding of AFB in nerve biopsy is not routinely made. It is also difficult to locate the offending drug in dermatitis medicamentosa, and challenging the patient with suspected offending drug runs the risk of flaring up the eruption severely. In chronic urticaria, often the causative agent cannot be pinpointed and is termed ‘idiopathic’. In clinically obvious tinea cruris or corporis, rarely the causative fungus is identified. In various eczemas, the treatment is, more often than not, based on clinical judgement. In treating a vitiligo patient, empirical treatment is still followed. In trichotillomania and neurotic excoriation, an in-depth psychological analysis is mostly not done.
The above narration of the Indian scene and, for the matter, a common scene of all developing countries only shows that what ‘Haves’ can afford, the ‘Have-nots’ unfortunately cannot. Let the ‘Haves’ have both the examinations—clinical and high-tech one, and the rest be satisfied with the clinical one unless highly imperative. And here lies the importance of clinical medicine and clinical dermatology.
One is happy to note that the American Journal of Clinical Dermatology claims to ‘promote rational therapy and effective patient management within the disciplines of dermatology and appearance medicine’. Happily, all recently published books, including textbooks, provide a good number of excellent coloured clinical photographs to emphasize on the clinical aspects of the described diseases. This, in fact, goes a long way to bedside clinical teaching in internal medicine, the importance of which can hardly be overlooked. The colour and smell of sputum, stool and urine give us a lot of prima facie information and provide important clues towards diagnosis. There are records that in ancient India, a careful examination of pulse could give enough information regarding the condition of the patient so as to provide even the prognosis.
Clinical judgement gives the solid data-base which one can ill-afford to neglect in dermatology, particularly when even histological diagnosis is not always infallible. Histology depicts only a particular stage of evolution of the disease. Every disease has a characteristic pattern of clinical evolution and rarely the same could be followed accurately even by having a series of temporal histological specimens. Even spongiosis, the hallmark sign or eczema, may not be found in the very early stage. But symptoms and signs in dermatology are of great diagnostic value. The pruritus and its intensity can be judged only by applying the mind and not by any instrument. The diagnosis of scabies (the itch) mainly depends on the symptoms and signs which must be allowed to speak for themselves. Just as a skilful statistician finds from the apparent mess 14of figures facts of significance, a good clinician may also bag useful information for diagnostic purpose by applying his eyes (physical and mental) to see the signs and his ears to hear the symptoms.
Another feature of importance in clinical dermatology is the psychological aspect and is particularly felt in case of vitiligo. No amount of evidence that it is just a cosmetic disorder can help remove the patient's mental depression. What is needed most to do good to the patient is a skilled reassurance by the physician. And here lies the importance of patient-doctor relationship.
In conclusion, the scientific value of clinical dermatology in diagnosis of disorders is convincingly clear and it is not possible to dislodge it from its unique position of importance. The edifice of ‘evidence-based dermatology’ can only be built on the sure foundation of clinical dermatology. Its importance is all the more glaringly established in the perspective of developing nations. In the final analysis, however, there is no inherent quarrel between clinical dermatology and evidence-based dermatology. They are not antagonistic but complementary to each other—a relationship of symbiosis. While we shall not be blind to science and its development, we shall not also be blinded by it. A torch-light is focussed only at night in the dark and not in daytime when the sun steadily shines. We must appear logically sensible. No microscope, simple or compound, polarising or electron, is of any avail without our physical eyes. Let not our ‘clinical eyes’ be allowed to get lost.
REFERENCES
  1. Heymann RW. Foreword, Goodhearts Photoguide of common skin disorders, 2nd ed, Lippincott Williams and Wilkins,  Philadelphia,  2003; XIII.
  1. Cochrane D. Aim and Scope, Am J Clin Dermatol 2001; 2: 389–406.