Manual of Rational Skin Therapy and Dermatological Drugs Sanjay Ghosh, Kisalay Ghosh, Saurav Kundu, Vikas Shankar
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Rational Skin TherapyCHAPTER ONE

  1. To search and manage background etiological factors, if any
  2. Topical tretinoin 0.025 to 0.05% once daily at evening or night
  3. Topical tazarotene 0.05% once daily at evening or night
  4. Oral metformin in obese patients with or without diabetes.
Milder Form
  • Topical retinoids: Adapalene, tretinoin, isotretinoin or tazarotene
  • Alternatives: Azelaic acid or salicylic acid.
Mixed and Papular/Pustular
Topical retinoids or azelaic acid and topical antimicrobials.
Moderate Form
Mixed and Papular/Pustular
  1. Oral antibiotic and topical retinoids with or without benzoyl peroxide
  2. Alternative: Oral antibiotic and azelaic acid with or without benzoyl peroxide
  3. In females: Oral antiandrogens and topical retinoids/azelaic acid with or without benzoyl peroxide.
  1. Oral antibiotic and topical retinoids with or without benzoyl peroxide
  2. Alternative: Oral isotretinoin or oral antibiotic and azelaic acid with or without benzoyl peroxide3
  3. In females: Oral antiandrogens and topical retinoids/azelaic acid with or without oral antibiotics.
Severe Form
  1. Oral isotretinoin
  2. Alternatives: High dose oral antibiotics and topical retinoids and benzoyl peroxide
  3. In females: High dose oral antiandrogens and topical retinoids with or without topical antimicrobials.
Maintenance Therapy
Topical retinoids with or without benzoic acid.
Acne Scar
Topical retinoid 2 weeks prior to and following therapy along with sunscreen and moisturizers.
Atrophic Scar
  1. Icepick scar: Punch excision, elevation and grafting, laser resurfacing/dermabrasion, spot TCA peel
  2. Rolling scar: Micrograft and subcision, filler, resurfacing, microdermabrasion, deep spot TCA peel
  3. Box scar: Laser skin resurfacing with or without punch elevation, fractional thermolysis, dermabrasion, CO2 laser resurfacing.
Keloidal Scar
Intralesional corticosteroids or 5-FU or bleomycin, topical imiquimod after intralesional excision, cryotherapy, pulsed dye laser.
Hypertrophic Scar
Intralesional corticosteroids or 5-FU or bleomycin, vascular laser, topical imiquimod after intralesional excision.
  1. Oral zinc supplementation: 30 to 50 mg of elemental zinc [2 to 3 times of normal recommended daily allowance (RDA)] until all symptoms and signs disappear.
  2. Further monitoring of the dose is to be done by follow-up blood zinc levels.
  1. Sunscreen
  2. Topical 5-fluorouracil (5-FU)
  3. Topical imiquimod 5%
  4. Photodynamic therapy
  5. Topical adapalene gel
  6. Topical diclofenac gel 3.0% (in 2.5% hyaluronan gel)
  7. Cryosurgery
  8. Curettage
  9. Excision
  1. Sunscreens
  2. Class II or I topical corticosteroids
  3. Narrow-band UVB phototherapy
  4. PUVA photochemotherapy.
  1. Penicillin: Parenteral penicillin G 10-20 million U/day intravenously divided every 6 hourly, depending on the severity, for 4 to 6 weeks. Follow-up therapy to be continued with penicillin V 250 to 500 mg, 4 to 6 times daily for 12 to 18 months. Penicillin K (phenoxymethyl penicillin) can also be given.
  2. Amoxycillin 500 mg 4 times daily may be tried in severe cases.
  3. In patients allergic to penicillin doxycycline 100 mg twice daily for 8 weeks
  4. Imipenem for 4 weeks in relapsed cases may be successful.
  1. Immediate withdrawal of offending drug
  2. Hospitalization
  3. Usually self-limiting: No specific therapy available
  4. Supportive therapy
  5. Emollients when superficial desquamation supervenes
  6. Topical corticosteroids
  7. Parenteral corticosteroids (single case report)
  1. Acute phase: Topical sterile normal saline soaking, topical corticosteroid solution
  2. Subacute phase: Topical corticosteroid cream or pimecrolimus 1% cream
  3. Chronic phase: Topical corticosteroid ointment or tacrolimus ointment 0.1%
  4. Systemic antibiotics, when signs of secondary infection or associated lymphangiitis or cellulitis seen
  5. Oral antihistamines to alleviate itching, irritation, if associated
  6. Short course of oral corticosteroids in case of severe contact dermatitis6
  7. Refractory cases: UVB NB, PUVA, azathioprine 100-150 mg/day for 6 months (reported in airborne parthenium contact dermatitis) or cyclosporine 5 mg/kg/day.
  1. Intralesional corticosteroids (triamcinolone acetonide) in patchy cases
  2. Potent topical corticosteroids for minimum 3 months especially in children (3 to 10 years)
  3. Topical immunotherapy with diphenylcyclopropenone (diphencyprone or DPCP): Initially 2% lotion is applied to a small area (2 to 4 cm2) of scalp for sensitization. Then lower concentration (0.001 to 0.1%) is weekly applied over a larger area.
  4. Topical PUVA can be attempted in children
  5. Topical minoxidil, topical anthralin, topical retinoic acid or PUVA: Insufficient evidence.
  6. Alopecia totalis/universalis: Short course systemic corticosteroids with a tapering schedule can be used.
  • Topical minoxidil 2 to 5% 1 ml twice daily
  • Finasteride 1 mg per day.
  • Topical minoxidil 2% 1 ml twice daily
  • Systemic antiandrogen cyproterone acetate 52 mg daily on days 1-20 of the cycle.
  1. Topical antifungals: Clotrimazole, miconazole
  2. Topical antibacterials: Mupirocin, fusidic acid
  3. Sytemic antifungals: Fluconazole
  1. Antiseptic mouth rinse (chlorhexidine gluconate) thrice daily for 6 weeks
  2. Sucralfate suspension 4 times daily even up to 2 years
  3. Topical corticosteroids (triamcinolone 0.1% in orabase)
  4. Tetracycline 250 mg/ 5 ml to be taken 4 times daily (to be held in the mouth for 2 minutes then swallowed)
  5. Amlexanox (5% oral paste) to apply 4 times daily
  6. Oral thalidomide 100 mg once daily for 2 months (200 mg in HIV+ patients)
  7. Oral colchicine 0.5 mg thrice daily for 4 months
  8. Oral corticosteroids: Prednisolone 40 mg daily once daily for 5 days, then 20 mg on alternate days for a week. Topical corticosteroids can be added along with.
  1. Topical corticosteroids
  2. Topical immunomodulators
  3. Emollients
  4. Oral antihistamines
  5. UVB NB
  6. PUVA
  7. Antibiotics
  8. Systemic corticosteroids
  9. Elimination diets
  10. Dust mite reduction
  11. Azathioprine: 2.5 mg/kg daily × 3 months
  12. Cyclosporine: 5 mg/kg daily × 6 to 26 weeks
  13. UVA1 phototherapy
  1. In treatment of Mycobacterium marinum infection:
    1. There is no consensus regarding treatment regimen and duration of therapy.
    2. Available effective drugs include doxycycline, ethambutol, minocycline, rifampicin, cotrimoxazole, clarithromycin, amikacin, levofloxacin either used alone or in combination.
    3. Excision of lesion is controversial. They should better be left for infection involving deeper structure. Chemotherapy should continue.
    4. The role of wearing gloves during handling of fish should be propagated by public awareness program.
  2. In treatment of Mycobacterium chelonae infection:
    1. No consensus treatment protocol exists.
    2. Treatment is dictated by clinical involvement. In minor localized disease single drug therapy is sufficient. Multiple drug is required for disseminated or systemic disease.
    3. Effective drugs include clarithromycin, erythromycin, doxycycline, amikacin used either alone or in combination.
    4. Duration of therapy is empirical.
    5. Surgical debridement may be adjunctive to medication.
  3. In treatment of Mycobacterium fortuitum infection:
    1. No consensus treatment protocol exists.
    2. These group is less drug-resistant compared to Mycobacterium chelonae infection.
    3. Effective drugs include amikacin, cefoxitin, ciprofloxacin, imipenam, tobramycin, sulfonamides, etc.
    4. Tetracycline as a group is ineffective.
    5. Surgical debridement may be adjunctive.
  1. Excisional surgery
  2. Radiotherapy
  3. Cryotherapy
  4. 5-fluorouracil (5 FU)
  5. Curettage and electrodessication
  6. Intralesional interferon-α (1.5 million unit three times in a week for 3 weeks)
  7. Topical imiquimod
  8. Photodynamic therapy
  1. Sucralfate
  2. Topical or intralesional corticosteroids
  3. Topical tacrolimus
  4. Chlorhexidine gluconate
  5. Tetracycline suspension
  6. Amlexanox 5% paste
  7. Colchicine 0.6 mg thrice daily
  8. Dapsone 100 to 200 mg daily
  9. Thalidomide 100 to 300 mg daily
  10. Systemic corticosteroids
  11. Clofazimine 100 to 400 mg daily.
  1. Potent topical corticosteroids
  2. Systemic corticosteroids: Oral prednisolone 0.5 mg/kg for moderate disease and 1 m/kg for severe disease11
  3. Tetracycline 500 mg twice to four times daily
  4. Tetracycline 500 mg twice to four times daily along with nicotinomide 500 mg thrice daily
  5. Dapsone 50 to 100 g daily
  6. Azathioprin 2.5 mg/kg daily
  7. Mycophenolate mofetil.
  1. Topical antifungals: Topical polyenes or azole antifungals
  2. Systemic antifungals: Fluconazole or itraconazole
  3. Topical antifungals and topical low potent corticosteroids.
  1. Flucloxacillin
  2. Cephalosporins: Cefazolin, ceftriaxone
  3. Amoxicillin with clavulanic acid
  4. Ciprofloxacin
  5. Teicoplanin
  6. Imipenem/cilastatin
  7. Phenoxymethylpenicillin: Oral prophylaxis.
  1. Azithromycin 1 g orally single dose
  2. Ceftriaxone 250 mg intramuscularly single dose
  3. Ciprofloxacin 500 mg twice daily for 3 days
  4. Erythromycin 500 mg 4 times daily for 7 days.
  1. Nifedipine 20 mg thrice daily for 6 weeks
  2. Diltiazem 60 mg thrice daily
  3. Topical corticosteroids under occlusions
  4. Minoxidil 5% lotion thrice daily application.
  1. Topical corticosteroids
  2. Topical tacrolimus
  3. UVB
  4. PUVA
  5. Hydroxychloroquin 200 mg once to twice daily
  6. Azathioprine 50 mg thrice daily for 6 to 8 weeks.
  1. Initial evaluation for other sexually transmitted infections
  2. Patient self-administered podophyllatoxin (0.5%) twice daily for 3 days per week for 4 weeks.
  3. Weekly painting of lesions with 25% of podophyllum resin and washing off after 1 hour.
  4. Topical imiquimod (5%) applied on and around lesion thrice weekly for a maximum of 16 weeks.
  5. Liquid nitrogen cryosurgery every 1 to 3 weeks till the lesion clears.
  6. Electrosurgery, curettage or carbon dioxide LASER can be used in larger or resistant lesions.
  7. Women with genital wart require to undergo periodic papsmear routinely and colposcopy when indicated.
  8. Presence of genital ulcer does not mandate cesarean delivery.
  9. Intralesional bleomycin, intralesional (or systemic) interferon-α or interferon-α or candidial antigen are used in selected cases.
  10. HPV vaccine: A quadrivalent (types 6, 11, 16, 18) and a bivalent (types 16, 18) recombitant vaccine can reduce the incidence of genital wart and cervical cancer significantly if used in time.
Macular Amyloidosis
  1. Potent topical corticosteroids with or without occlusion
  2. UVB NB.14
Lichenoid Amyloidosis
  1. Potent topical corticosteroids with or without occlusion
  2. Topical tacrolimus 0.1% ointment
  3. Dermabrasion
  4. Oral retinoids (acitretin 35 mg daily for 6 months)
  5. UVB or PUVA.
Nodular Amyloidosis
  1. Intralesional corticosteroids
  2. Excision
  3. Dermabrasion
  4. Laser (CO2, Nd:YAG, pulsed dye).
  • Oral albendazole 400 mg single dose or daily for 3 to 7 days
  • Oral ivermectin 12 mg single dose.
  • Topical thiobendazole 15% in lipophilic vehicle twice daily for 5 days.
Pentavalent Antimonials
  • Meglumine antimoniate: Intralesionally with local anesthetic or systemically 10 mg/kg daily for 2 weeks
  • Sodium stibogluconate: Intralesionally 1 to 2 ml weekly or 10 mg/kg IM/IV daily for 2 weeks.
Second Line Therapies
  • Rifampin
  • Amphotericin B
  • Allopurinol plus low dose meglumine antimoniate
  • Azoles (itraconazole, ketoconazole, fluconazole)
  • Cryotherapy.
  1. Keratolytic emollients
  2. Antiseptic cleansers
  3. Sunscreen
  4. Thin clothes
  5. Intermittent antibiotics and antifungals
  6. Mid-potent topical corticosteroids
  7. Topical retinoids
  8. Oral retinoids: Isotretinoin or acitretin (0.5 mg/kg/day as starting dose)
  9. Surgery.
  1. Removal of pressure
  2. Frequent change of position
  3. Air-fluidized or liquid-filled bed
  4. Wound dressings without trauma
  5. Debridement of necrotic debris
  6. Wound swab for bacterial culture and sensitivity
  7. Moist dressing
  8. Nutrition
  9. Topical antibacterials
  10. Hydrocolloid dressing
  11. Stage IV ulcer: Surgical intervention.
  • Gluten-free diet
  • Dapsone
  • Tetracycline and nicotinamide
  • Colchicine
  • Systemic corticosteroids
  • Topical corticosteroids.16
Cutaneous Involvement
  1. Sunscreen (high SPF with UVA protective agents)
  2. Topical corticosteroids
  3. Topical tacrolimus or pimecrolimus
  4. Hydroxycholoroquin or chloroquin
  5. Methotrexate (low dose: 5 to 15 mg weekly)
  6. Mycophenolate mofetil (1 gm twice daily).
Systemic Involvement
  1. Systemic corticosteroids (1 mg/kg gradually tapered to half dose over 6 months and very slowly reduced to stop totally after 2 to 3 years; may be given on alternate days or as pulse)
  2. Methotrexate (15 mg/m2 weekly)
  3. Azathioprine (2-3 mg/kg/day)
  4. Mycophenolate mofetil (1 gm twice daily)
  5. Intravenous immune globulin (2 g/kg body weight monthly infusion for 3 months with systemic steroids)
  6. Cyclophospamide (0.5 to 1.0 g/m2 monthly pulse).
  1. Frequent change of diaper
  2. Disposable absorbent diapers
  3. Barrier creams
  4. Repeated use of petrolatum
  5. Topical antifungal and antibiotic combination
  6. Topical hydrocortisone with topical antifungal and antibiotic combination.
  1. Decrease exposure to irritants like soap, over the counter moisturizer, etc. Infrequent washing by mild bar type soap or soap-free cleanser is recommended.
  2. Dryness must be controlled by proper bath and moisturizer application.
  3. Acute lesions are treated by wet dressing till dryness. Then discontinue to avoid excessive dryness.
  4. Topical application of class 2 to 4 corticosteroid is mainstay of therapy.
  5. Tar preparations may be used alone or in combination with topical steroid.
  6. Calcineurin inhibitors (tacrolimus and pimecrolimus) are also useful.
  7. Secondary infection should be treated with systemic anti-staphylococcal antibiotics.
  8. Sedative oral antihistaminic reduces itch.
  9. In widespread disease, systemic corticosteroids may be considered for a short period. Flare after drug withdrawal is expected.
  10. UVB (both broadband and narrowband) is useful in extensive disease. In resistant cases PUVA can be given.
  1. Broad spectrum sunscreen
  2. Topical or intralesional corticosteroids
  3. Topical tacrolimus or pimecrolimus
  4. Chloroquine or hydroxychloroquine
  5. Systemic retinoids
  6. Clofazimine (100 mg thrice in a week to daily)
  7. Dapone (25 to 150 mg daily).
  1. The first step in any cutaneous adverse drug reaction is to confirm the diagnosis and identify the implicated agent. These may not be possible in many cases because coexistence of viral exanthem, couse of multiple drugs and in Indian perspective random availability of non-prescription medicine.
  2. The second step is assessment of severity. The presence of following indicate severe drug reaction:
    • Fever, malaise, cough, arthralgia.
    • Erythroderma, facial edema, purpura, skin tenderness and mucosal involvement and lymphadenopathy.
  3. The third step is to take decision whether to withdraw or continue with the drug. This is done on a case-to-case basis depending upon the severity of reaction, importance of the implicated medication and presence of alternative.
  4. The fourth step is general care of the patient which is according to the clinical presentation.
  5. The fifth step is symptomatic management. This is done with systemic antihistamines, topical corticosteroid, topical calamine and/or moisturizer. Exception is acneiform drug eruption where topical tretinoin is used.
  6. Systemic steroid is used in severe drug eruption except in SJS-TEN (see below). The initial dose is 0.5-2 mg/kg prednisolone per day. The duration is dependent upon the reaction pattern and is usually longer in drug hypersensitivity syndrome.
  7. The next step is prevention of future reaction. Counseling the patient and providing with a probable drug list is essential. As SJS-TEN or drug hypersensitivity syndrome may run in families, a prior personal and family history is essential to reduce incidence of drug reaction.
  8. The final step is reporting the reaction to authority.
  1. Acyclovir 400 mg twice daily before food for 6 months to 2 years in recurrent EM.
  2. Oral valacyclovir 500 mg daily or famciclovir 250 mg twice daily (where inadequate response to oral acyclovir)19
  3. Topical corticosteroids in adhesive base for oral EM
  4. Clotrimazole troche or mouth paint and if required oral fluconazole in oral EM to combat secondary candidiasis.
  5. Oral levamisole (150 mg thrice in a week for 4 to 8 weeks) in recurrent oral EM.
  1. Bed rest with leg elevation
  2. To treat underlying diseases (especially infectious ones)
  3. To withdraw provoking drugs, if any
  4. NSAIDs (indomethacin 25 mg thrice daily or naproxen 250 mg twice daily for 1 month)
  5. Potassium iodide (Saturated solution of potassium iodide or SSKI)
  6. Colchicine (2 mg daily for 3 days, then 1 mg daily for 2 to 4 weeks)
  7. Hydroxychloroquine (200 mg twice daily for 3 months).
  1. Topical benzoyl peroxide 2.5% gel daily after shower for 7 days
  2. Topical erythromycin or clindamycin twice daily for 7 days
  3. Sodium fusidic acid 2% twice daily for 2 weeks
  4. Topical miconazole
  5. Topical clotrimazole
  6. Erythromycin 250 mg 4 times daily for 7 days (in refractory case).
General Measures
  1. Hospitalization
  2. Single room for the patient
  3. Control of room temperature (usually warm humid room with many blanket)
  4. Monitoring of fluid intake and output and renal function
  5. Electrolyte balance
  6. To watch for signs of cardiac failure
  7. Protein-fortified diet (approx 130% of normal balanced diet protein)
  8. Folate supplementation
  9. Bland emollients
  10. To avoid irritating topical agents like tar, anthralin, etc.
  11. To avoid salicylic acid to avoid salicylism through increased absorption.
  12. Systemic antibiotics
  13. Oral antihistamines.
Specific Measures
  1. Work-up to search underlying diseases or precipitating drugs
  2. Topical corticosteroids
  3. Systemic corticosteroids (only in idiopathic and drug-induced variant. Starting dose 1-2 mg/kg/day; maintenance 0.5 mg/kg/day or less)
  4. PUVA
  5. Systemic retinoids
  6. Cytotoxic drugs/antimetabolites
  7. Cyclosporine (in refractory psoriasis and atopic dermatitis)
  8. UVA1 phototherapy.
  1. Topical antibiotics: Mupirocin, fusidic acid
  2. Systemic antibiotics: Flucloxacilln, clindamycin (low dose: 150 mg 4 times daily or 300 mg twice daily for 7 to 14 days), fluoroquinolones, linezolid
  3. Surgery: Incision and drainage.
Recurrent Furunculosis
  1. Bacterial culture and sensitivity from the fresh lesion.21
  2. Rifampicin 600 mg daily for 7 to 10 days along with semisynthetic penicillin, cephalosporin, minocycline, or ciprofloxacillin
  3. Mupirocin cream or ointment to apply twice daily to the anterior nares for a week. This procedure can be repeated every month at a fixed week for 3 months
  4. Antiseptic soaps.
Uncomplicated Infection (Urethral, Cervical, Rectal)
  1. Cefritaxone 125 mg IM single dose
  2. Cefpodoxime 400 mg orally single dose
  3. Ciprofloxacin 500 mg orally single dose
  4. Cefixime 400 mg orally single dose.
Pregnant Women
  1. Ceftriaxone 125 mg IM single dose
  2. Spectinomycin 2.0 g IM single dose (if cannot receive ceftriaxone).
Cotreatment for Chlamydia
  1. Azithromycin 1 g orally single dose
  2. Erythromycin 500 mg 4 times daily for 7 days
  3. Amoxicillin 500 mg thrice daily for 7 days.
  1. Azithromycin 500 mg orally daily for 7 days or 1 g orally weekly for 4 weeks
  2. Erythromycin 500 mg orally 4 times daily for minimum 3 weeks
  3. Trimethoprim-sulfamethoxazole double strength 1 tab twice daily for minimum 3 weeks
  4. Doxycycline 100 mg orally twice daily for minimum 3 weeks
  5. Ciprofloxacin 750 mg orally twice daily for minimum 3 weeks.
  1. Topical and intralesional corticosteroids
  2. Systemic corticosteroids (3 to 5 mg/kg daily for 6 to 12 weeks)
  3. Interferon alfa-2a or 2b
  4. Laser (continuous wave or pulsed dye)
  5. Surgical excision.
  1. Oral acyclovir
  2. Oral valacyclovir
  3. Oral famcyclovir
  4. Topical acyclovir
  5. Foscarnet (40 mg/kg once to thrice daily for acyclovir-resistant HSV usually in AIDS)
  6. Cidofovir (topical 0.3 or 1% gel for acyclovir-resistant HSV usually in AIDS)
  1. Acyclovir 800 mg 5 times daily for 7 to 10 days
  2. Famcyclovir 500 mg thrice daily for 7 days
  3. Valacyclovir 1 g thrice daily for 7 days
  4. Foscarnet 40 mg/kg every 8 to 12 hourly for 7 to 10 days in patients with suspected acyclovir-resistant herpes zoster
  5. Amitriptyline 75 to 100 mg daily for postherpetic neuralgia23
  6. Nortriptyline 50 to 100 mg daily for postherpetic neuralgia (to start with 10 to 20 mg daily)
  7. Gabapentin for postherpetic neuralgia (300 mg daily as starting dose; may be increased over 4 weeks up to 3600 mg/day in divided dose until therapeutic result is obtained or intolerable adverse effects set in).
  1. Topical clindamycin for 3 months
  2. Systemic tetracycline 250 to 500 mg 4 times daily until lesions resolve
  3. Erythromycin 250 to 500 mg 4 times daily until lesions resolve
  4. Minocycline 100 mg twice daily until lesions resolve
  5. Intralesional triamcinolone 3 to 5 mg/ml into the painful nodules
  6. Prednisolone 60 to 80 mg/day for 2 to 3 days tapered over 14 days may improve severe pain and inflammation dramatically. After stopping usually there occurs flare
  7. Oral isotretinoin not effective in established severe disease. In early disease, this may help to prevent follicular occlusion
  8. Cyproterone acetate may be effective only in high doses, which may yield adverse effects. Combination of cyproterone acetate plus ethinyl estradiol (30 μg/day for 21 days) may be more useful than any of these two single drugs
  9. Surgery: In acute abscess, recurrent painful nodules and sinus tract, extensive involvement.
  1. Initial assessment must include a scoring in modified Ferriman and Gallwey scale. 24Associated feature of androgen excess like thinning of hair or pustular acne should be looked for.
  2. Evaluation for presence of hyperandrogenism should follow. If present source of the excess androgen is sought.
  3. The treatment modality has three parts:
    1. Physical/chemical
    2. Pharmacological.
    3. Bleaching
  4. The physical/chemical part is essential for all. It targets the present terminal hair. It should be used alone or in combination with pharmacological therapy. Modalities of physical/chemical therapy includes:
    1. Depilatory process: Hair is removed at skin surface. Follicle remains intact. Popular methods are:
      • Shaving: Cheap and safe. Does not change rate and density of hair growth. Socially unacceptable.
      • Depilatory creams (hair removing cream): Malodorous and potentially irritant. Less chance of both with thioglycollate containing creams, but they are more time consuming.
    2. Epilatory process: Hair is removed at follicle level. Procedures include:
      • Plucking: Painful. May give rise to folliculitis and postinflammatory hyperpigmentation in Indian skin.
      • Waxing: It is a widespread plucking with all its disadvantages.
      • Electrolysis and electrothermolysis (using radiofrequency): Done under topical anesthesia (EMLA). Skin type and hair color are not a concern. Successful for white hair as well. Scarring may occur. Pretreatment with tretinoin cream reduce healing time.
      • Laser: Different lasers are efficient in removing pigmented hair only. White hairs are resistant. In Indian skin longer wavelength lasers like Nd:YAG laser is safe. Safety of other laser or IPL is less in type V and VI skin. Side effects include thermal burn, postinflammatory hyperpigmentation and scarring. Single session reduces 10-20% of existing hair making multiple sessions necessary.
  5. Pharmacological therapy: Essential in hirsutism with androgen excess but also effective in idiopathic hirsutism with normal androgen level. Usually ineffective on existing hair. Visible effect is seen in 6-12 months. Available agents marginally differ in efficacy. Choice of agent depends on patient profile, associated disease or need of patient and experience of clinician with that particular agent. Available therapies are:
    • Oral contraceptive pill: The selection of the progestin component is important. Drospirenone is the preferred agent. Initial evaluation should concentrate on OCP side effect like DVT.
    • Cyproterone acetate: Available in combination with ethinyl estradiol in India. High estrogen content increases the chance for DVT and weight gain.25
    • Spironolactone: Used in 100-200 mg/day, it is effective but associated with menstrual irregularity. Combined use with OCP offers good menstrual control and offers protection from pregnancy (spironolactone in pregnancy cause feminization of male fetus).
    • Finasteride: Used in 2.5-5 mg daily dose (with OCP in female of child-bearing age group to prevent feminization of male fetus).
    • Metformin: Particularly useful in PCOS and other form of insulin resistance.
    • Bromocriptine: Useful in hyperprolactinema.
    • Systemic corticosteroid: Prednisolone (5-10 mg) or dexamethasone (0.2-0.5 mg) taken at bedtime is useful in hirsutism with congenital adrenal hyperplasia.
    • Eflornithine hydrochloride 13.9% cream applied twice daily is effective in 8 weeks. They act by blocking ornithine decarboxylase. Result is temporary. Regrowth seen within 8 weeks of drug withdrawal. Should be combined with other mode. May cause irritation.
  6. Bleaching: 6% hydrogen peroxide bleach makes hair less visible.
  7. Weight reduction is an essential component to reduce circulatory androgen level.
  1. Treatment modality is to be decided on severity of disease and occupation of the patient.
  2. General measures like frequent wash with deodorant soap, changing socks daily, wearing cotton socks and leather shoes without rubber or leather soles should be stressed.
  3. Palmoplantar and axillary hyperhidrosis is treated with 20% aluminium chloride hexahydrate in absolute alcohol. Initially applied high time with or without occlusion every night till desired reduction in sweating achieved. Then once weekly maintenance regimen is followed. Local irritation is important adverse effect.
  4. Tap water iontophoresis for 15-30 minutes daily and then 2-3 times weekly is effective. Direct current is more effective though less tolerated. Addition of glycopyrrolate solution potentiates effect but may be associated with systemic absorption.
  5. Local injection of botulinum toxin A placed 1-2 cm apart in a checkerboard pattern to deliver the drug in superficial dermis is the most effective treatment. A single session effect lasts for 6-9 months.
  6. Sympathectomy and sympathotomy may offer benefit in severe and recalcitrant cases. Nowadays endoscopic method is preferred.
  7. Liposuction and curettage of sweat gland can be done in axillary hyperhidrosis.
  8. Systemic anticholinergic drugs are effective but seldom tolerated.26
  9. Sedatives are sometime helpful.
  10. Relaxation techniques like biofeedback training may reduce sweating.
  1. Skin hydration is maintained with adequate bath or soak and immediate application of moisturizer. Drying agents are discouraged.
  2. Mild keratolytics like α-hydroxy acids (lactic acid, glycolic acid), β-hydroxy acid (salicylic acid) and urea help in scale removal.
  3. Propylene glycol (40-60% in water) with or without occlusion helps in scale removal.
  4. Topical retinoids or vitamin D3 analogues though effective is poorly tolerated.
  5. Systemic retinoids like acitretin or isotretinoin are indicated in severely affected patients like lamellar ichthyosis, congenital ichthyosiform erythroderma.
  6. In epidermolytic hyperkeratosis antistaphylococcal agents (topical or systemic) are required to reduce bacterial infection.
  7. Nutritional supplementation is required in severe variety of congenital ichthyosis to prevent growth failure.
  8. Proper eye and lip care should be undertaken. Opinion from ophthalmologist is essential in ectropion seen in lamellar ichthyosis.
  1. Wet-dressing with burrow's solution or potassium permanganate can reduce oozing and removes crust.
  2. In limited disease, topical antibiotic like mupirocin or fusudic acid is sufficient.
  3. More extensive lesion requires systemic antibiotic therapy.
  4. Antibiotic is chosen with compatibility to age, sex and the demographic sensitivity profile.
  5. Most clinicians prefer dicloxacillin or 1st generation cephalosporins.27
  6. In penicillin sensitive patients macrolides may be used though emerging resistance pattern restrict their use.
  7. Clindamycin is a suitable alternative.
  8. In recurrent diseases colonization (particularly nasal) should be eliminated by application of 2% mupirocin ointment.
  9. Weight reduction, frequent bath with antibacterial soaps, change of clothing and maintenance of personal hygiene is recommended.
  10. In resistant cases, oral rifampicin can be used.
  11. Predisposing factors like diabetes mellitus and HIV in suspected cases should be investigated.
  1. Avoidance of insect contact is essential.
  2. Use of dress cover, mosquito net and insect repellants should be advised according to patient profile.
  3. Existing lesion can be treated with class 3 or 4 topical corticosteroid.
  4. Secondary pyodermas are treated with topical or systemic antibiotic.
  5. In pediatric patient, parent counseling about the self-resolving nature of the disease is important to alleviate anxiety.
  1. No consensus treatment exists. Treatment modality is decided according to:
    1. Location and size of lesion.
    2. Experience of the clinician with particular therapeutic option.
    3. Patient profile.
    4. Cost of therapy.
  2. Intralesional triamcinolone remains the primary mode with dermatologists because most patients have smaller lesion without functional impairment.
  3. Cryotherapy immediate prior intralesional injection reduces toughness of keloid and makes injection easier.
  4. Mixing triamcinolone with lignocaine reduces pain.
  5. Initial concentration of triamcinolone is kept high (40 mg/ml). Later lower concentration (2-5 mg/ml) is chosen to avoid unnecessary atrophy.
  6. Role of silicone gel is controversial. It can be chosen as a modality after consulting the patient.28
  7. Cryotherapy alone is effective in smaller and newer lesion. Associated depigmentation restricts use in Indian skin. Combination with intralesional triamcinolone is helpful (see 3).
  8. Surgical excision is helpful in removing larger and functionally impairing keloid.
  9. To prevent recurrence excision is combined with skin grafting and pressure dressing of donor and recipient site along with any one of the following
    • Radiotherapy.
    • Intralesional corticosteroid or interferon-α
    • Topical imiquimod.
  10. Laser (carbon-dioxide, Nd:YAG) therapy in keloid is associated with high recurrence rate and not recommended routinely. Pulse dye Laser is claimed to be successful in trials; clinical application is not delineated.
  11. In predisposed patients keloid formation can be reduced by:
    1. Avoid unnecessary surgery.
    2. When essential prior radiotherapy of the proposed surgical site may be considered.
    3. Clean cut scalpel surgery is preferred over electrosurgery.
    4. Wound closure should take place without tension.
    5. Infection rate to be kept at minimum.
    6. Pressure dressing is mandatory.
  1. Keratosis pilaris is mostly a cosmetic concern.
  2. Comorbidity like atopic dermatitis, ichthyosis vulgaris or nutritional deficiencies should be sought and treated.
  3. Majority improves by adulthood.
  4. Aggravating factors like tight fitting clothes, abrasive scrubs are to be avoided.
  5. Use of moisturizer on regular basis reduces the dryness and inflammation.
  6. Topical tretinoin imparts temporary and partial improvement. Irritation may be a limiting factor.
  7. Application of 12% ammonium lactate cream/lotion twice daily improves roughness.
  8. Low potent topical steroid may be used to reduce associated inflammation. Long-term use is not recommended.
Venous Ulcer
  1. Leg elevation
  2. Compression stockings
  3. Dressings
  4. Debridement (autolytic, hemical and/or mechanical)
  5. Wound swab for culture and sensitivity
  6. Antimicrobial treatment (topical and/or systemic)
  7. Management of surrounding stasis dermatitis, if any
  8. Surgery.
Arterial Ulcer
  1. To stop smoking, if present
  2. Low cholesterol diet
  3. To control hypertension, DM, hyperlipidemia
  4. Lipid-lowering agents
  5. Anti-platelet agents (aspirin or clopidogrel)
  6. Cilostazol, an inhibitor of phosphodiesterase III
  7. Exercise to develop collateral circulation
  8. Elevation of head of the bed by 4 to 6 inches
  9. Local wound management
  10. To keep the legs warm
  11. Hyperbaric oxygen.
  1. Dapsone 100 mg daily
  2. Rifampicin 600 mg monthly once (supervised).
  1. Dapsone 100 mg daily
  2. Clofazimine 50 mg daily
  3. Rifampicin 600 mg and clofazimine 300 mg one monthly (supervised).
Second Line of Drugs
  1. Minocycline 100 mg daily
  2. Ofloxacin 400 mg daily
  3. Levofloxacin 500 mg daily once or twice
  4. Clarithromycin 500 mg twice daily.
Mild Type 1 Reversal Reaction (RR) or ENL
NSAIDs (ibuprofen or aspirin)
Severe RR
Prednisone 0.5 to 1.0 mg/kg once to twice daily to start immediately and to continue for 3 to 6 months, then to be slowly tapered.30
Severe RR or ENL
Clofazimine 100 mg thrice daily for 6 weeks and then reduced to 100 mg daily for several months.
Severe ENL
  • Thalidomide 100 mg at night; may be increased up to 400 mg daily
  • Prednisolone 0.5 to 1.0 mg/kg daily.
Management of LE specific skin lesion is primarily a dermatologist's job. Systemic involvement is managed by an internist/rheumatologist.
Following measures are to be taken in a step-ladder pattern:
  1. Photoprotection:
    1. Physical photoprotective measures:
      1. Outdoor activities to be restricted before 10 am and after 4 pm even on cloudy days (more than 80% of sunray penetrate cloud cover).
      2. UV rays are reflected from water, concrete, sand, snow, tile, and reflective window glass in buildings. The window glass blocks some UV rays, especially UVB, but significant UVA pass through. Plastic adherent films that block all UVB and UVA rays should be applied to home and car windows.
      3. Clothing can provide sun protection. Dark colored tightly woven fabric gives best protection. Umbrella or 4 inch wide brimmed hats should be used while outdoor.
    2. Sunscreens: Sunscreens should be applied liberally to all exposed parts 15 to 30 minutes before sun exposure with particular attention to the posterior neck, the ears, and the areas of the scalp covered with thin hair. Choose a sunscreen with at least 30 SPF with additional UVA—blocking property. Adults using sunscreen regularly should take daily oral supplementation (400 to 800 units) of vitamin D.
  2. Topical corticosteroids (class 1-2), tacrolimus and/or pimecrolimus (on face mainly), intralesional triamcinolone in isolated lesion.
  3. If no response
    1. Start hydroxychloroquine at 6.5 mg/kg/day
    2. Measures for smoking cessation in smokers.
    3. If no response seen by eight weeks quinacrine 100 mg/day should be added.
    4. If no improvement felt in next 4 weeks replace hydroxychloroquine with chloroquine 250 mg/day and continuing quinacrine.
  4. If no response after several weeks, dapsone, a systemic retinoid, clofazimine or gold remain therapeutic options.31
  5. If the above treatments fail, or cannot be tolerated, thalidomide or immunosuppressive agents like short-term systemic steroids, methotrexate, azathioprine, mycophenolate mofetil or cyclosporine should be considered.
  6. Patients with severe disease may be treated with immunosuppressive agents, in combination with the antimalarials in the initial phase.
  7. Biologics: Efalizumab, rituximab, abatacept have been shown to be effective in recalcitrant disease. They themselves may induce DLE. More experience required regarding their use in LE.
  1. Mostly asymptomatic and self-limiting. So, no intervention is required.
  2. Treatment is given either in symptomatic ground (severe itching) or cosmetological concern.
  3. Topical glucocorticoid induce remission. Short course of oral glucocorticoid may be helpful in extensive or symptomatic disease.
  4. Phototherapy, both narrow and broad band UVB and systemic PUVA are also helpful.
  5. In resistant cases, acitretin, low dose cyclosporine has been reported to be effective.
  1. Topical or intralesional corticosteroids is the mainstay of therapy.
  2. Systemic steroid is indicated in eruptive lichen planus, erosive mucosal lichen planus.
  3. Topical calcineurin inhibitors show variable response.
  4. Systemic retinoids, like acitretin (30 mg/day) or isotretinoin (20-40 mg/day) shows marked improvement in cutaneous, oral and nail lesion with a mean treatment duration of 4 months.
  5. Cyclosporine mouthwash is useful in unresponsive, erosive oral lichen planus.
  6. Systemic cyclosporine with a low dose range of 3-10 mg/kg/day is used in recalcitrant lichen planus. Azathioprine and mycophenolate mofetil may also be used in recalcitrant generalized lichen planus.
  7. Use of dapsone, hydroxychloroquine or thalidomide can be considered in a case-to-case basis.
  8. PUVA therapy is useful in generalized cutaneous disease. Success is also reported with narrow band UVB and UVA1 phototherapy.
  9. Symptomatic therapy includes lignocaine and diphenhydramine in painful, erosive mucosal lichen planus and sedative antihistamine in cutaneous disease.32
  10. Lichen planopilaris is best-treated with potent topical glucocorticoid along with systemic glucocorticoid. Concomitant use of topical glucocorticoid with systemic glucocorticoid arrests progression.
  11. Lichen planus hypertrophicus is treated with potent corticosteroid under occlusion or intralesional corticosteroid.
  1. Treatment of mucous membrane lichen sclerosus is started with class 1 topical corticosteroid like clobetasol.
  2. The duration is kept below 4 weeks to reduce atrophy.
  3. The continuation phase treatment includes either less potent corticosteroid or calcineurin inhibitors like tacrolimus.
  4. Intralesional corticosteroid like triamcinolone acetonide are useful for isolated unresponsive plaque.
  5. Acitretin (20-0 mg/day) is useful in severe recalcitrant disease. Isotretinoin may also be used.
  6. Cryotherapy and laser (both ablative and non-ablative) are useful in selected cases.
  7. Vulvectomy is necessary in secondary squamous cell carcinoma.
  8. Circumcision resolves penile LS and associated phimosis.
  9. Asymptomatic extragenital LS seldom require any treatment.
  1. Potent topical steroid of class 1 to 3 with or without occlusion is the mainstay of therapy.
  2. Nonsteroidal topical anti-inflammatory agents like menthol or pramoxine can also reduce itch.
  3. Adequate moisturization increases therapeutic efficacy of the above agents.
  4. The role of scratching in the disease process needs to be explained to the patient. Cutting of nails and occluding the lesion with plastic films or steroid impregnated tape is essential.
  5. Stress plays a role in aggravation. Stress reduction should be attempted.33
  6. Night-time itch should be controlled by sedative antihistamines or tricyclic antidepressants.
  7. Selective serotonin reuptake inhibitors are helpful in daytime pruritus or in obsessive-compulsive disorder.
  8. Grenz-ray is also effective.
  1. Oral doxycycline 100 mg twice daily for 21 days is the treatment of choice.
  2. If doxycycline is contraindicated erythromycin base at a dose of 500 mg four times a day is given orally.
  3. Oral azithromycin 500 mg weekly for 3 weeks is curative but safety in pregnancy is not established.
  4. Sexual partner within prior 30 days should also be treated.
  5. Therapy may be prolonged in HIV-positive patients. Treatment should continue till complete resolution of all signs and symptoms take place.
  6. Aspiration of buboes is required if they do not respond to medical therapy.
  7. Aspiration is done by a lateral approach through healthy skin to avoid fistula formation.
  8. In late complication surgery is required to reduce morbidity. It includes rectal stricture dilatation, rectovaginal fistula repair, genital reconstruction, etc.
  1. Initial evaluation should be based on clinical parameter instead of Wood's lamp finding because in Indian skin that is seldom yielding.
  2. Patient should be counseled about the slow response to treatment, persistence of dermal pigmentation, importance of sun avoidance and effect of drugs particularly hormonal contraceptives on therapeutic outcome.
  3. Art of sun-protection by physical method should be explained. These will be supplemented by a SPF 30 sunscreen with avobenzone as a component for UVAI protection.
  4. Classical depigmentary agents like hydroquinone (2-4%), azaleic acid(15-20%), kojic acid or arbutin are the mainstay of therapy.
  5. Tretinoin (0.025-0.1%) is also helpful alone or in combination.
  6. Class 4 to 6 corticosteroids are useful but side effect like atrophy and telangiectasis restrict their use.
  7. Modified Kligman formula incorporates the above three drugs to increase efficacy and reduce toxicity.34
  8. Chemical peel by α-hydroxy acids are effective in unresponsive cases.
  9. Efficacy of laser is not well established.
  1. Heat exposure must be terminated to alleviate symptom.
  2. Air conditioning or frequent cold bath is recommended.
  3. Topical coolant like calaminol may be appreciated by the patient.
  4. Eczematous change is treated with topical corticosteroid.
  5. As miliaria causes destruction to sweat duct an attack is followed by reduction in sweat volume and resultant xerosis for a few days. Advice emollients.
  1. Majority molluscum contagiosum lesions are self-limiting. So watchful expectancy is the primary mode of management.
  2. Curettage to remove the infectious core is rapid and painless though in children topical EMLA cream should be considered.
  3. Liquid nitrogen cryotherapy is also rapid but painful particularly in genital lesion. Topical anesthesia is mandatory.
  4. Cantharidin (0.7 or 0.9%) is applied with a wooden stick on lesion. It is left for 4 hours. A blister develops in 24 hours that resolves along with the lesion.
  5. Topical application of podophyllin in 10 to 25% suspension in physician's office is useful. It is washed after 1 to 4 hours. Podophyllotoxin is equally effective with less adverse effect and can be home applied.
  6. 5% imiquimod cream applied alternate day cures 80% of molluscum.
  7. Topical cidofovir (1%, 3% cream or gel) is effective but costly.
  8. Topical retinoids, 5-fluorouracil, silver nitrate paste, 10% KOH and trichloroacetic acid (25-50%) are alternative mode of therapy.
  9. Oral cidofovir and subcutaneous interferon-α are indicated in resistant lesions in immuno-compromised patients.
  10. Oral cimetidine (40 mg/kg/day) is used in extensive lesions.
  11. Anti-retroviral therapy is effective in molluscum contagiosum in HIV/AIDS.35
  1. Intervention is necessary in more severe disease which can cause irreversible fibrosis and damage.
  2. Topical or intralesional steroids are mainstay of therapy. Systemic steroid may be required in more aggressive disease.
  3. Calcipotriol with or without UVAI phototherapy is beneficial in children.
  4. Antimalarials may be used as substitute.
  5. Other immunosuppressants like cyclosporine, methotrexate, cyclophosphamide, azathioprine, etc. have been reported to be successful.
  6. Penicillin and depenicillamine are effective.
  7. PUVA, broadband UVA and UVAI phototherapy alone or in combination is efficacious.
  8. Physical therapy in the early stage maintains joint mobility and reduces morbidity.
  1. In eumycetoma medical therapy is mostly unsuccessful.
  2. Ketoconazole, itraconazole, fluconazole, voriconazole, posaconazole and terbinafine have all been used in eumycetoma caused by sensitive organism in different studies. Their role in clinical set-up is not clear.
  3. Amputation is the only definitive curative procedure in advanced cases but the value of such procedure in a non life-threatening infection should be weighted in a case-to-case basis.
  4. In actinomycetoma caused by nocardial species trimethoprim-sulfamethoxazole is the drug of choice.
  5. Amikacin injection can be combined for better result.
  6. In patients sensitive to sulfaminocycline or amikacin-imipenem combination gives good result.
  7. In actinomycetoma caused by actinomycetes a combination of dapsone with streptomycin or trimethoprim-sulfamethoxazole with streptomycin or amikacin is used.36
  8. Duration of therapy is long and patient specific.
  9. Surgical debridement is considered on a case-to-case basis.
Stage 1
  1. Emollients
  2. Topical corticosteroids
  3. Topical chemotherapy
  4. PUVA or UVB
Stage 2
Stage 1 regimen and
  1. Local radiotherapy
  2. Interferon-α -2a
Stage 3
  1. Interferon-α -2a
  2. Methotrexate (low dose)
  3. Extracorporeal photochemotherapy
  4. PUVA
Stage 4
Stage 1 and 3 regimen and
  1. Combination chemotherapy
  2. Radiotherapy to lymph nodes
  1. Wet soaks followed by class 1 corticosteroids application is primary mode of therapy. Unresponsive cases may require occlusion.
  2. Maintenance is done with anthraline, tazarotene or calcipotriol.
  3. In persistent cases, PUVA can be used alone or in combination with acitretin.
  4. In disabling disease or disease with frequent recurrence systemic retinoid acitretin can be used. Teratogenecity restricts use in child-bearing age group.
  5. Methotrexate or cyclosporine can be used as an alternative.
  6. Efalizumab is claimed to be successful but experience is limited.
  1. In small plaque parapsoriasis treatment is not mandatory and patient may opt for no treatment. So counseling is essential before initiating therapy.
  2. Treatment is initiated with topical corticosteroid (class 3 to 5) along with emollient.
  3. If not responsive to the above regimen UVB (both broadband and narrowband) should be considered.
  4. In the initial phase re-evaluation is done 3 monthly to identify any deviation from the stable nature of SPP.
  5. In the later phase, yearly evaluation is sufficient.
  6. Large plaque parapsoriasis is potentially malignant and every effort is spent to arrest progression of the disease and early identification of a lymphomatous change.
  7. Initial therapy is started with topical corticosteroid (class 1 to 3) with phototherapy (BBUVB, NBUVB or PUVA).
  8. Poikilodermatous type can be treated with topical nitrogen mustard.
  9. Patient evaluation is done every 2-3 month to assess progression.
  10. If sign of spread detected multiple biopsies should be taken from suspected areas.
  11. Cases satisfying clinicopathological criteria of patch stage MF should be treated as cutaneous lymphoma.
  12. Stable cases are evaluated yearly.
  1. Acute paronychia is bacterial in origin.
    • Treated with systemic antibiotic initially. As most cases are staphylococcal or streptococcal a semi-synthetic penicillin (dicloxacillin) or 1st generation cephalosporin (cephalexin) is chosen.
    • In β-lactam sensitive person a macrolide (erythromycin or azithromycin) is used.
    • If no response is seen in 48 hours, incision and drainage should be considered.
    • Further antibiotic selection is dictated by the culture-sensitivity of the drained pus.
  2. Chronic paronychia is multifactorial in origin. Treatment centers on:
    • Hand care:
      1. Water and irritant contact should be kept to minimum.
      2. Wearing cotton gloves under rubber gloves is mandatory during work.
      3. Frequent application of thick moisturizer like white soft paraffin is helpful.38
    • Treatment of the infection:
      1. Secondary candidal colonization should be treated by topical or if required systemic antifungal.
      2. Systemic antifungals (fluconazole or itraconazole) are particularly effective when candidal onychomycosis is present.
      3. Topical antibiotic can be used in the initial phase.
      4. Systemic antibiotic is needed when acute paronychia sets in.
    • Treatment of the inflammation:
      1. Dry heat application.
      2. Application of topical corticosteroid (class 3)
  1. Permethrin 1 to 5% is applied on dry scalp for 10 minutes is an effective pediculocide.
  2. 0.5% malathion applied for 8-12 hours is also effective but use is limited by adverse effects.
  3. Second application for all pediculocide except lindane is recommended due to variable ovicidal activity and lack of patient compliance.
  4. Cotrimoxazole is an effective antibacterial agent with an ability to kill adult lice.
  5. Oral ivermectin at a dose of 250 μg/kg body weight given 7-10 days apart is very effective. Use not recommended for patient below 15 kg.
  6. All members of household needs to be examined and affected one has to be treated.
  7. Bedding, clothing, comb, floor should be cleaned according to recommendation to prevent recurrence.
  8. The treatment modality for pediculosis pubis is same as above. Sexual contacts should be treated along with the affected household members.
  9. Petrolatum applied thickly over eyelid twice daily for 2 weeks removes eyelid lice.
  10. For pediculosis corporis, bathing, laundering infested clothing in hot water followed by hot ironing (specially the seam of the clothing) and maintenance of personal hygiene is only required.
  11. Some prefer to treat with 5% permethrin cream, left for 8-10 hours.
  12. Dusting of clothing with malathion or permethrin based tick repellant is recommended to prevent recurrence.
  1. Glucocorticosteroids: 2 to 3 mg/kg of body weight till new bullae formation stops and Nikolsk's sign becomes negative. Then the dose can be rapidly tapered to half of the starting dose when the patient's skin is almost free of blisters. From this point very slow tapering of dose is to be done to attain a minimally effective maintenance dose.
  2. Adjuvant immunosuppressives:
    1. Azahiprine: 2 to 3 mg /kg body weight till complete clearing, then tapering to 1 mg/kg
    2. Cyclophosphamide: 100 to 200 mg daily; tapering to 50 to 100 mg/day. Or in ‘pulse’ therapy: 1000 mg IV once in a week or every 2 weeks in ‘staring’ dose, then 50 to 100 mg /day as maintenance
    3. Mycophenolate mofetil: 1.5 to 2 g daily
  3. Fluid and electrolyte balance
  4. Antimicrobial therapy, when required
  5. Topical or intralesional corticosteroids
  6. Wet dressings
  7. Cleansing baths
  1. There is no consensus treatment modality. Even no treatment remains an option.
  2. Topical corticosteroids are first line therapy.
  3. Calcineurin inhibitor tacrolimus can be used, particularly in maintenance.
  4. Phototherapy (BBUVB, NBUVB or PUVA) is the most effective mode.
  5. Systemic antibiotics like erythromycin (500 mg twice to four times daily), tetracycline (500 mg twice to four times daily) or minocycline (100 mg twice daily) are other options.
  6. Systemic corticosteroid, methotrexate, ciclosporin, dapsone or IVIG are very rarely required.
  1. Treatment is initiated with topical corticosteroid with phototherapy (BBUVB, NBUVB, PUVA, natural sunlight) in mild-to-moderate disease.
  2. Oral antibiotics like erythromycin (500 mg twice to four times daily), tetracycline (500 mg twice to four times daily) or minocycline (100 mg twice daily) are other options.
  3. Severe disease is treated with tapering dose of systemic corticosteroid initially.40
  4. Dapsone can be used as a steroid sparing agent.
  5. Steroid unresponsive cases are managed with methotrexate (10-25 mg PO/week), cyclosporine (2.5-4 mg PO divided in 2 doses/day) or acitretin (25-50 mg PO/day)
  1. Most patients do not require treatment. Counseling regarding the self-resolving nature of PR is sufficient.
  2. If the pruritus is troublesome topical menthol, pramoxine or topical corticosteroid (class 4-6) can be considered.
  3. Night-time sedative antihistamines also reduce itch.
  4. Role of oral erythromycin is controversial.
  5. Oral acyclovir 800 mg 5 times daily for 7 days has shown to be effective in patients of PR with flu like symptom or extensive skin lesion.
  6. Phototherapy with BBUVB or sunlight is also effective but may result in postinflammatory-hyperpigmentation particularly in Indian skin.
  7. Systemic corticosteroid may be required in very few patients with severe disease. Tapering must be slow to avoid resurgence.
  1. Consensus treatment is lacking. Therapeutic regimen is chosen according to the clinical severity, patient profile and personal experience of concern physician.
  2. For erythrodermic stage acitretin (0.5-0.75 mg/kg body wt) is the drug of choice along with general management for erythroderma. Isotretinoin (0.5-1 mg/kg/day) is preferred in pediatric population.
  3. Methotrexate (10-25 mg weekly) remains 2nd option medication. It is used alone when acitretin cannot be started or in combination when acitretin alone is partially effective.
  4. Phototherapy (BBUVB, NBUVB, PUVA, UVA1) alone or in combination with acitretin is useful. Due to possibility of photoaggravation phototesting prior starting of therapy is mandatory.
  5. Extracorporeal photopheresis is useful in patients with severe symptom when the above regimens fail.
  6. The role of other systemic agents like azathioprine, cyclosporine, fumaric acid esters and TNF-α antagonist is yet not clear.
  7. Vitamin D3 analogues and topical retinoid tazarotene is also effective.
  8. Topical corticosteroid (class 1-3) is considered a 2nd line therapy when step 6 and 7 fails.41
  9. Phototherapy remains another option in localized disease.
  10. For patients of PRP who are suffering from HIV/AIDS, HAART is very effective.
  1. 2% ketoconazole in a shampoo base applied on affected areas for 5 minutes for 3 consecutive days is curative.
  2. 2.5% selenium sulfide shampoo is a cheaper alternative but requires 10 minutes contact for 7-14 days and has got a bleaching effect.
  3. Monthly application of both the agents is recommended for prevent recurrence.
  4. In resistant cases, oral antifungals like ketoconazole (200 mg/day for 7 days), itraconazole (100-200 mg twice daily for 7 days) or fluconazole (400 mg single dose) can be used.
  5. Associated hypopigmentation may remain for longer period. Phototherapy can be used in persistent cases.
  6. Topical tretinoin is effective in hyperpigmented variety.
  1. Avoidance of sun including UVA. It should be explained to the patient that UVA penetrates the glass and so sunray in a room coming through glass window may precipitate PMLE lesion.
  2. Proper sunscreen should be chosen. It should have a high SPF with additional UVA blocking property. Application method and the common mistakes in sunscreen application should be emphasized to the patient.
  3. Mild variety responds to topical corticosteroid (class 3-5) or calcineurin inhibitors.
  4. A small burst of systemic corticosteroid may be helpful.
  5. Prophylactic phototherapy in spring can be considered in severely affected patients. PUVA is most effective followed by NBUVB and BBUVB. Some patient can have a flare with initiation of phototherapy. It should be treated with systemic corticosteroid.
  6. Efficacy of hydroxychloroquine is moderate.
  7. If the above modes fail, introduce other immunosuppressives like azathioprine or cyclosporine.
  1. Wet dressing with Burrow's solution or diluted potassium permanganate (1:8000) reduces vesiculation.
  2. Oral antihistamines can reduce pruritus. Patient should be counseled about stress reduction.
  3. Topical corticosteroids (class 1-3) with or without occlusion are mainstay of therapy, ointment preparation is preferred over cream.
  4. Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are also effective but lack the potency of corticosteroids. They are used in rotation with corticosteroids to avoid steroid-induced atrophy.
  5. Short course of systemic corticosteroids (0.5-1 mg/kg/day tapered over 1-2 weeks) is sometimes useful in recurrent pompholyx, if initiated at the beginning of pruritus. Long-term use is prohibited.
  6. Phototherapy is effective in recurrent disease. Among phototherapeutic options PUVA and UVAI is more effective than UVB.
  7. Grenz-ray can also be beneficial.
  8. Patients of pompholyx who also suffer from hyperhidrosis may benefit from iontophoresis, intradermal botulinum toxin or sympathectomy.
Polymorphic Eruption of Pregnancy (PUPPP)
  1. Important differential diagnosis is from pemphigoid gestationis, which is a rarer and more significant disorder.
  2. Treatment is usually with topical corticosteroids and chlorpheniramine; however, corticosteroids may add to the tendency for striae, and sedating antihistamines may be best avoided prior to delivery to avoid fetal sleepiness manifesting as poor fetal movement
Pemphigoid Gestationis
  1. Treatment of typical cases is with systemic corticosteroids, (dose 0.5 mg/kg) [should not exceed 80 mg/daily] which may need to be continued for several months after completion of the pregnancy. 43Even when most activity has settled, premenstrual exacerbations may occur.
  2. If blisters occur in the baby, these are transient, as they are due to passively transferred immunoglobulin across the placenta.
  3. It is important to recognize that milder versions do occur and may be amenable to control with topical corticosteroids alone, although proof of the disorder by biopsy for immunofluorescence is worthwhile in view of the risks of recurrence.
  4. Refractory cases: Plasmapheresis, IVIG, cyclosporine.
  5. Maternal complications: Nil/ increased risk of Grave's and other autoimmune disease.
  6. Fetal risk: Small for their gestational age, prematurity.
Impetigo Herpetiformis
  1. Treatment is usually limited to systemic steroids (15-20 mg/d) and UV therapy
  2. Other choice: Cyclosporine (category C drug).
Cholestasis of Pregnancy
  1. Weekly fetal monitoring since 34 weeks
  2. Early induction of labor: 37-38 weeks
  3. Pruritus: Cholestyramine (may precipitate Vit K trigger coagulopathy), ursodeoxycholic acid (UDCA) 450-1200 mg daily: Safe, well-tolerated, decreases fetal mortality)
Pruritic Folliculitis of Pregnancy
10% benzoyl peroxide +1% hydrocortisone
Papular Dermatitis of Spangler
High dose of prednisone (40-200 mg/d)
  1. Treatment of prurigo nodularis is a clinical challenge.
  2. Itching should be alleviated with night-time use of sedative antihistaminic or tricyclic antidepressant.
  3. Selective serotonin reuptake inhibitors can be used to control daytime pruritus.
  4. Topical antipruritic agent like menthol, calaminol or pramoxine can reduce itch. Emollients are also effective particularly if itch is associated with xerosis.
  5. Topical corticosteroids (class 1-2) are mainstay of initial therapy. Occlusion potentiates their efficacy.
  6. Intralesional corticosteroids are effective but sometimes the lesions are too many to be injected.44
  7. Vitamin D3 analogue calcipotriene or calcineurin inhibitor tacrolimus may have steroid sparing effect but lacks potency.
  8. Phototherapy particularly PUVA is effective in certain cases.
  9. Thalidomide is very effective. Therapy is initiated at 100 mg/day and later titrated to lower dose to avoid dose-dependent neuropathy (appears at a cumulative dose of 40-50 gm).
  10. UVB and thalidomide can be sequentially used to reduce toxicity of both.
  11. Cyclosporine at a dose of 3-4.5 mg/kg is very effective in resistant cases. Long-term use is restricted due to adverse effect.
  12. Cryotherapy can be adjunctive.
Mild-to-Moderate Skin Involvement
  1. Topical corticosteroids (TCS): Mild-to-superpotent depending on the anatomical location, thickness of lesion, duration of the lesions, etc. TCS may be combined with salicylic acid in ointment base on very thick hyperkeratotic lesions especially on palmoplantar area or lotion base for thick lesions on scalp.
  2. Topical calcipotriene ointment, cream or solution. To start with calcipotriene may be combined with TCS to reduce inflammation.
  3. Topical tar ointment for skin or lotion for scalp and hairy skin.
  4. Topical anthralin: Preferably as short contact therapy on localized skin lesions
  5. Topical tazarotene with or without TCS
  6. Topical tacrolimus or pacrolimus: In intertriginous or facial lesions
  7. UVB NB or PUVA in refractory cases.
Severe Involvement
  1. <10% BSA (body surface area) involved (sensitive area/refractory)
    • Superpotent TCS +Calcipotriol/Tazarotene/Anthralin
    • If not response add UVB NB
    • If not response add PUVA/PUVASOL
    • If not response add UVB NB + Acitretin
    • If not response add methotrexate (If contraindicated add cyclosporine/ biologics).
  2. >10% BSA involved
    • UVB NB
    • If not response add PUVA/PUVASOL
    • If not response add UVB NB + Acitretin
    • If not response add MTX (If contraindicated add cyclosporine/ biologics).
Difficult Situations
  1. Childbearing age: UVB NB /PUVA/ Cyclosporine/Biologics
  2. Pregnancy: UVB NB/Cyclosporine/Oral corticosteroids/Biologics45
  3. Hepatic dysfunction and alcoholics: UVB NB/Cyclosporine.
  4. In HIV diseases: UVB NB/ UVB NB+ Acitretin.
Methotrexate: Indications
  • Erythodermic psoriasis
  • Pustular psoriasis
  • Psoriatic arthritis
  • Extensive psoriasis unresponsive to less toxic therapies
  • Psoriasis affecting patient's economic or psychological wellbeing
  • Not responsive to phototherapy, PUVA, or retinoids.
Acitretin: Indications
  • Monotherapy in generalized pustular psoriasis
  • Combination with UVB or PUVA in severe plaque Ps, localized palmoplantar Ps, pustular Ps.
Cyclosporine: Indications
  • Erythrodermic Ps
  • Pustular Ps
  • Pts with hepatic dysfunction and alcoholics
  • MTX-intolerance and MTX-induced hepatic damage
  • In severe Ps with pregnancy.
Biological Therapy in Psoriasis: Indications
Basic Criteria
  • PASI score 10 or more (or BSA 10% or more)
  • DLQI>10
  • Severe for 6 months
  • Resistant to treatment
  • Pt candidate for systemic therapy
Pt should fall in one of the following clinical criteria:
  • Developed or at higher risk of developing clinically important drug-related toxicity and where alternative standard therapy (acitretin, MTX, UVB NB, PUVA) cannot be used
  • Intolerant, cannot receive or unresponsive to standard therapy
  • Disease that requires repeated inpatient management for control
  • Significant coexisted unrelated morbidity which precludes use of other systemic agents like cyclosporine and MTX
  • Severe unstable, life-threatning diseases like pustular psoriasis or erythrodermic psoriasis
  • Psoriatic arthritis
    (British Association Dermatology Guidelines, BJD 2005)
Difficult Psoriasis: Choice of Biologics
  • Acute phase/ Pustular Ps (generalized)/ Erythrodermic/Indoor admitted patients: Infliximab
  • Chronic plaque/severe/refractory patients not willing to undergo IV infusion by admission/traveling frequently/had H/o tuberculosis or exposure: Etanercept
Rotational Therapy
  • Objects: To minimize cumulative toxicity of individual drugs and to prevent resistance
  • Examples: PUVA→ MTX→ Retinoids.46
Combination Therapy
  • Aims: To enhance response, to reduce side effects by lowering individual doses
  • Examples: TCS + calcipotriol/Phototherapy
    • Acitretin+ phototherapy
  • Contraindicated Combinations:
    • Acitretin+ Cyclosporine
    • PUVA/UVB + Cyclosporine
    • PUVA+ Methotrexate
Sequential Therapy
  • Objects
  • To clear psoriasis by potent agent initially
  • Maintain remission by safer, less effective agents
  • Example: Cyclosporine followed by Retinoids + PUVA.
  1. Shaving should be stopped till inflammation resolves.
  2. The embedded hair shaft is removed by inserting a sterile needle under the hair loop. A toothbrush rubbing in a circular motion can also be used for the same purpose.
  3. Topical azelaic acid should be prescribed to reduce bacterial colonization and post-inflammatory hyperpigmentation.
  4. 5% benzoyl peroxide alone or in combination with topical 1% clindamycin is also effective.
  5. Systemic antistaphylococcal antibiotics are sometimes essential to enhance healing.
  6. Intralesional triamcinolone (2.5 mg/ml) is sometimes required for persistent papule. Care is to be taken to avoid atrophy.
  7. Shaving may be resumed once lesions heal.
  8. Use of eflornithine hydrochloride 13.9% cream reduces hair growth and may prevent relapse.
  9. Depilatory creams can also be tried.
  10. In recurrent cases despite above measure shaving needs to be stopped.
  11. Laser hair removal by Nd:YAG Laser is safe in type III to V skin and offers permanent cure from pseudofolliculitis. Diode Laser and IPL are also effective though safety is not warranted in Indian skin.47
  1. Patient should be oriented about available treatment modalities, their adverse effects and slow response of the disease to treatment.
  2. Bed rest and pain control is essential in the initial phase of severe disease. Associated anemia should be corrected.
  3. In acute stage wound care principle:
    1. Potassium permanganate (1:2000) solution wash reduces exudation. Tepid normal saline wash is another alternative.
    2. Wound is smeared with 1% silver sulphadiazine cream.
    3. A nonadhesive dressing is held in place firmly by a crepe bandage. Care should be taken not to put it too tight.
  4. Vegetative or small ulcerative lesion can be treated with local measures.
    1. Class 1 or 2 topical steroid applied on the periphery of an active PG lesion can induce healing.
    2. Intralesional triamcinolone (5-10 mg/ml) twice weekly at the edge of a lesion can induce healing.
    3. Topical tacrolimus is an option for peristomal and early PG.
  5. In larger lesion, multiple lesions, aggressive spread, lesion unresponsive to topical measures and disease associated with significant morbidity systemic therapy is chosen. Options are:
    1. Oral prednisolone 0.5-1.5 mg/kg/day is started and continued till the lesion shows sign of healing. Then slow tapering is initiated.
    2. Use of pulse steroid is not recommended in steroid unresponsive cases. In this condition, use cyclosporine at a dose of 3-6 mg/kg /day either alone or in combination with prednisolone.
    3. In steroid responsive cases where prolong therapy is suspected a steroid sparing agent is introduced. Choices are in the form of dapsone (50-200 mg/day orally), or minocycline (100-200 mg/day orally in 2 divided doses), or clofazimine (100 mg 3 times daily orally).
    4. Methotrexate is helpful in patients with IBD.
    5. Systemic tacrolimus, mycophenolate mofetil and azathioprine can be used alone or in combination with systemic steroid. Any consensus related to their use has not been formed yet. Owing to the severe adverse effects of these agents, a case-to-case basis decision should be taken.
    6. Same principle is maintained in the use of biologicals (infliximab, etanercept, adalimumab) in PG.
  6. Skin grafting is not recommended due to pathergy, but cultured keratinocyte autograft and bovine collagen matrix are useful. 48Disease activity should be kept minimum using step 6.
  7. Gradient support hosiery is helpful in lower extremity PG.
  8. Follow-up: Ulcerative PG lesions are relapsing in nature. Follow-up protocol is to be decided upon
    1. Initial response to therapy.
    2. Presence of associated illness.
    3. Cost.
  9. Prevention protocol includes:
    1. Avoidance of trauma.
    2. In planned operation in a patient with severe PG following guidelines should be followed:
      • Systemic corticosteroid during and after (2 weeks or more) surgery
      • Use of subcuticular suture
    3. Surgeon should be warned about development of peristomal PG in patients suffering from Crohn's disease and PG.
  1. Aggravating factors like hot and spicy food, red wine and sunlight should be avoided.
  2. A gentle broad-spectrum ultraviolet A and ultraviolet B sunscreen should be applied. Use of umbrella and broad-brimmed hat as well as restricted daytime outdoor activity should be stressed.
  3. Harsh cosmetic ingredients like camphor, menthol and sodium lauryl sulfate should not be used.
  4. A soap-free cleanser is preferred for cleansing.
  5. Topical barrier repair emollient use is mandatory particularly in dry and sensitive skin.
  6. Cosmetic camouflage with a green tint is recommended.
  7. For erythematotelangiectatic subset
    • 10% sodium sulfacetamide-sulfur cleanser in the morning followed by cosmetic camouflage with moisturizing sunscreen is advised.
    • At night a metronidazole (0.75 or 1%) or azelaic acid (15%) formulation is preferred.
    • For moderate-to-severe flushing oral tetracycline (500 mg twice daily) or isotretinoin (0.5 mg/kg body wt/day) is effective.
    • Vascular lasers and IPL are effective in reducing redness and telangiectasia.
    • Topical tretinoin can be used as maintenance therapy.
  8. For papulopusular subset
    • Morning application includes any one from topical metronidazole, azelaic acid, sodium sulfacetamide-sulfur or benzoyl peroxide-clindamycin combination along with a sunscreen.
    • At night any one of the morning products that was not used in morning is applied.49
    • For moderate-to-severe flushing oral tetracycline (500 mg twice daily) or isotretinoin (0.5 mg/kg body wt/day) is effective.
    • Topical isotrenoin is used for maintenance
  9. For phymatous subset
    • Benzoyl peroxide-clindamycin combination is most effective among topical therapy.
    • Oral tetracycline or isotretinoin is used depending on severity.
    • Surgical intervention according to need.
  10. For ocular subset
    • Skin care as step 7.
    • 10% sodium sulfacetamide ophthalmic ointment is helpful.
    • Oral tetracycline, if topical management fails.
    • Ophthalmologist's opinion should be sought.
Cutaneous Sarcoidosis
  1. Corticosteroids: systemic for generalized or scarring lesions; intralesionally 3 mg/ml or potent topical corticosteroids for limited lesion
  2. Hydroxychloroquine 100 mg twice daily
  3. Methotrexate: Low dose
  4. Others: Anti-TNF α-blockers, thalidomide.
Systemic Sarcoidosis
Indications of systemic corticosteroids:
  1. Active ocular disease
  2. Active pulmonary disease
  3. Cadiac arrhythmia
  4. CNS involvement
  5. Hypercalcemia.
  1. Permethrin 5% cream applied from neck-to-toe (head-to-toe in pediatric cases and when involvement of those areas seen in an adult) for 8-14 hours and repeated in 7 days is the mainstay of therapy. It is a pregnancy category B drug, but not recommended in infant under 2 months of age.
  2. 1% lindane lotion is around 89% curative but increased resistance is being reported. Nonetheless the drug is toxic and not recommended in children below 2 years, in pregnancy and lactation.
  3. Crotamiton and precipitated sulfur are of limited efficacy.50
  4. Oral ivermectin 200 μg/kg body weight given 7-10 days apart is highly effective, safe and recommended along topical agents in resistant or crusted cases.
  5. To prevent recurrence all close contacts to be treated with a topical scabicide.
  6. Clothing and bedlinen used in last 5 days before treatment should be hot washed or dry cleaned.
  7. The associated pruritus in scabies may last for 4 weeks and proper patient counseling is required. Otherwise treatment failure is suspected.
  8. Pruritus can be controlled by oral antihistamines, topical corticosteroids or in severe cases with a short course of systemic steroid.
  9. Associated pyoderma should be treated with systemic antibiotic.
Raynaud's Phenomenon
  1. Behavioral therapy
  2. To avoid cold exposure
  3. Calcium channel blockers: Nifedipine
  4. Angiotensin II receptor blocker: Losartan
  5. IV alprostadil (prostaglandin E1) in refractory case
  6. Oral iloprost, a prostacycline analogue
  7. Oral sildenafil.
Cutaneous Ulcers
  1. Topically applied growth factors like PDGF
  2. Bosentan (oral endothelin receptor antagonist approved for SSC-related pulmonary hypertension).
Cutaneous Sclerosis
  1. D-penicillamine: Controversial role; low dose (62.5 mg/day) equally effective with lesser side effects as compared to higher dose (750 to 1000 mg/day)
  2. Minocycline: Anti-inflammatory and antifibrotic effects
  3. Methotrexate: Helpful in SSC patients with overlap dermatomyositis.
Calcinosis Cutis
  1. No effective therapy available
  2. Low dose warfarin, which does not alter prothrombin time
  3. Calcium channel blockers.
  1. Seborrheic dermatitis (SD) of infant has excellent prognosis. But in adults the disease is recurrent in nature. This nature should be explained to the guardian or the patient at the beginning of therapy.
  2. In infant SD should be managed as below:
    1. Scalp: The purpose is to remove of crust/scale, reduce fungal growth and inflammation. Following drugs can be used either alone or in combination:
      1. 3% salicylic in olive oil
      2. Warm olive oil compress
      3. Class 5/6 topical steroid for a short period
      4. Topical antifungal shampoo: Maximum experience is with 2% ketoconazole shampoo. The recommended regimen is twice weekly with a 5 minutes contact period. The shampoo should be applied to involved facial skin. Povidone iodine shampoo is also effective.
      5. Mild baby shampoos are helpful in early cases.
      6. Systemic antibiotic is used in suspected secondary bacterial infection.
    2. Intertriginous area: Options are
      1. Drying lotions like calamine application
      2. Nystatin or amphotericin B or gentian violet, if available may be used.
  3. The adult SD is managed as below:
    1. Scalp: The principal is same as infantile SD. Available modalities are:
      1. Selenium sulfide 2.5% shampoo. Irritation and bleaching is use limiting side effect. Contact period is 5-10 minutes. Used 2-3 times/week it is equally effective as ketoconazole.
      2. Ketoconazole 2% shampoo
      3. Zinc pyrithione shampoo
      4. Salicylic acid
      5. Topical glucocorticoid (class 5-7)
      6. Topical calcineurin inhibitors like tacrolimus (additional antifungal activity) and pimecrolimus.
      7. Vitamin D3 analogue (calcipotriol, calcitriol or tacalcitol)
      8. Avoid hair oil, soap, hair tonic, etc.
    2. Face: Recommendations are
      1. Avoid greasy ointment and soap.
      2. Topical ketoconazole 2% cream
      3. Topical corticosteroid (class 5-7)
      4. Topical calcineurin inhibitor
      5. Vitamin D3 analogue
    3. Seborrheic blepharitis: Modalities are
      1. Hot compress and gentle debridement
      2. Baby shampoo to remove crust/scale
      3. Sodium sulfacetamide ophthalmic ointment.
    4. Seborrheic otitis externa: Modalities are
      1. Topical corticosteroids (class 5-7)
      2. Topical calcineurin inhibitors
      3. Aluminium acetate solution.52
  4. If step 3 fails proceed to either of the following:
    1. Systemic antifungal therapy
    2. UVB phototherapy: Disease may flare in a few.
    3. Oral isotretinoin: 0.05-0.1 mg/kg/day for several months can clear resistant cases. Mandatory precaution in childbearing age group.
    4. Systemic corticosteroid: May be helpful in acute flare. Prednisolone 30 mg/ day produces a rapid response. Long-term use is not recommended.
  1. Suspect diagnosis and confirm clinically, histologically and immunologically but initiate treatment with clinical suspicion.
  2. Identification of the implicated drug is essential but difficult in many cases due to multiple drug use. If causative drug cannot be identified, the basic idea is to discontinue all nonessential drugs introduced in last 8 weeks and essential drugs in the high-risk list should be replaced by an alternative.
  3. Next step is withdrawal of all suspected drugs and replace them if necessary with suitable noncross-reacting alternative.
  4. Prognostic work-up is done with ‘SCORTEN’.
  5. Basic management includes:
    • Hemodynamic equilibrium: Peripheral channel is preferred mode. Fluid balance is maintained like a burn patient.
    • Temperature regulation: 28-30°C is the optimal temperature.
    • Nutritional support
    • Wound care: Detached or detachable skin should be left in place as biological dressing. Only sloughed or necrotic skin is removed. Wound is irrigated with potassium permanganate (1: 10000) solution and the denude area is covered with nonadhesive dressing. Collagen dressing can be used. Petrolatum impregnated gauze piece is a cheaper alternative.
    • Prevention of infection: Prophylactic antibiotic is not recommended. Aseptic care is essential. Routine culture of skin, blood and urine specimen is done for bacteria and fungi in intervals.
    • Eye care: Referral to ophthalmologist is mandatory. Antibiotic eye drops and ointment, artificial tear supplementation, and mechanical disruption of synechiae are eye-saving.
    • Mouth and genital care: According to the severity to avoid pain and complication.53
  6. Specific treatment till date is elusive. The following drugs may have a place:
    • Systemic corticosteroid: High dose short burst of corticosteroid may be helpful if given in early stage of disease before denudation has taken place. Use is controversial.
    • Intravenous immunoglobulin: Small trial shows success, but larger trial is lacking. Use is routinely not recommended. If used, consideration of adverse effects should be done.
    • Cyclosporine: Small case report shows success. Larger trial required.
    • Plasmapheresis: Routine use not recommended.
    • Antitumor necrosis factors: Due to increased mortality with thalidomide, these agents are not recommended.
  1. Cutaneous lesion is primarily treated with any one of the following regimen:
    1. Saturated solution of potassium iodide:
      1. Start with 5 drops three times daily which is to be increased to 30-50 drops three times daily.
      2. Should be taken with orange juice to mask the taste. Milk remains an inferior alternative.
      3. After resolution of lesion therapy should continue for another 3-4 weeks.
      4. This drug is inexpensive but has multiple adverse effects.
    2. Oral itraconazole:
      1. Given at a dose of 200 mg per day.
      2. Should be continued for at least 1 week beyond clinical resolution.
      3. Expensive but tolerable adverse effect profile.
    3. Oral terbenafine:
      1. Given at a dose of 250 mg per day.
      2. Should be continued for at least 1 week beyond clinical resolution.
      3. Expensive but tolerable adverse effect profile.
  2. Localized heat therapy at 38.5° C is effective. Should be combined with drug therapy.
  3. Intravenous amphotericin B is used for systemic infection.54
  1. Primary, secondary and early latent:
    Primary therapy: Benzathine penicillin G 2.4 million units IM single dose
    Alternative: Doxycyclin 100 mg orally twice daily × 7 days
    • Ceftriaxone 1 g IM daily × 8 to 10 days
    • Tetracycline 100 mg orally 4 times daily × 7 days
  2. Latent of unknown duration and late latent:
    Primary therapy: Benzathine penicillin G 2.4 million units IM once weekly × 3 weeks
    Alternative: Doxycyclin 100 mg orally twice daily × 28 days
    • Tetracycline 100 mg orally 4 times daily × 28 days
  3. Neurosyphilis:
    Primary therapy: Aqueous penicillin G 18-24 million units IV daily (3-4 million units every 4 houry or continuous infusion) × 10 to 14 days
    Alternative: Procaine penicillin 2.4 million units IM daily plus probenecid 500 mg orally 4 times daily × 10 to 14 day
    • Ceftriaxone 2 g IM once daily × 10 to 14 days
    • Tertiary (excluding neurosyphylis):
    • Benzathine penicillin G 2.4 million units IM once weekly × 3 weeks
  1. Treatment of dermatophyte infection is site specific.
  2. In treatment of tinea capitis:
    1. Topical antifungals like selenium sulfide, povidone iodine, zinc pyrithione or ketoconazole have adjunctive role.
    2. Systemic antifungals are mainstay therapy. Griseofulvin (20-25 mg/kg/day), fluconazole 6 mg/kg/day), itraconazole (3-5 mg/kg/day) and terbinafine (3-6 mg/kg/day) are available options.
    3. Duration of therapy is species specific. Prior culture is essential.55
    4. Systemic corticosteroid is used to relieve pain, swelling and resultant scarring. Oral prednisolone 1-2 mg/kg/day is given for first one week of antifungal therapy.
  3. In treatment of tinea barbae: Follow same principal as tinea capitis. Only adult dosages of antifungals are slight different. They are
    1. Griseofulvin 1000 mg/day for 2-4 weeks.
    2. Fluconazole 200 mg/day for 4-6 weeks.
    3. Itraconazole 200 mg/day for 2-4 weeks.
    4. Terbinafine 250 mg/day for 2-4 weeks.
  4. In treatment of tinea corporis:
    1. Topical antifungals applied twice daily for 2-4 weeks are used for localized disease. Drugs include allylamines, imidazoles, butenafine, ciclopirox, tolnaftate.
    2. Systemic antifungals are used for extensive and inflammatory lesions. Dosage regimen are
      • In adult:
        • Griseofulvin 500 mg/day for 2-6 weeks
        • Fluconazole 150 mg/week for 4-6 weeks
        • Itraconazole 100 mg/day for 2 weeks
        • Terbinafine 250 mg/day for 2 weeks.
      • In children:
        • Griseofulvin 10-20 mg/kg/day for 6 weeks
        • Itraconazole 5 mg/kg/day for 1 week
        • Terbinafine 3-6 mg/kg/day for 2 weeks.
  5. In treatment of tinea cruris: Treatment modality is same as tinea corporis. Inflammation may be more due to maceration. Keeping the area dry is essential. Weight reduction and wearing loose under clothing are important adjunctive measure.
  6. In treatment of tinea pedis:
    1. Topical antifungals are sufficient for localized noninflammatory interdigital tinea pedis. Same drugs as in tinea corporis with same dosing schedule are prescribed.
    2. For more extensive, inflammatory or refractory disease systemic antifungals are used.
      • In adult, dosage are
        • Fluconazole 150 mg/week for 3-4 weeks.
        • Itraconazole 200 mg twice daily for 1 week.
        • Terbenafine 250 mg/day for 2 weeks.
      • In children, itraconazole 5 mg/kg/day for 2 weeks.
    3. Treatment of associated onychomycosis is essential to avoid relapse.
    4. Maceration and foul smell indicate secondary bacterial infection which is quite common. Antibiotic should be added to the regimen if gram-stain and culture proves superinfection.
    5. Systemic corticosteroid at a dose of 0.5-1 mg/kg/day for 7-10 days is required in bullous tinea pedis.
  7. In treatment of tinea manuum: Same as tinea pedis.
  8. In treatment of onychomycosis:
    1. Topical therapy by ciclopirox or amorolfine is effective when nail matrix has not been involved.56
    2. With matrix involvement systemic agents are required. Choices are
      • Fluconazole 150-300 mg/weekly for 3-12 month (In refractory case, use 450 mg per week)
      • Itraconazole 400 mg/daily for 1 week per month. Two months therapy is given for fingernail and 3 month for toenail.
      • Terbinafine 250 mg/daily for 6 weeks for fingernail and 12 weeks for toenail.
  1. HIV testing is mandatory in all patients of cutaneous tuberculosis before initiation of therapy because seropositive patients may require prolong therapy.
  2. Ideally culture and sensitivity is to be done as multidrug resistant tuberculosis is rising. This is not possible in most clinical set-up.
  3. Empirical therapy is initiated with 4 drug regimen for first 8 weeks. Dosage protocol as below:
    1. Rifampicin: 10 mg/kg/day orally
    2. Isoniazid: 5 mg/kg/day orally
    3. Pyrazinamide: 30 mg/kg/day orally
    4. Ethambutol: 15 mg/kg/day orally or streptomycin 15 mg/kg/day IM.
  4. Maintenance is continued with 2 drugs for 16-18 month. Dosage are
    1. Rifampicin: 10 mg/kg/day orally
    2. Isoniazid: 5 mg/kg/day orally
  5. Surgical intervention may be used in conjunction with antitubercular chemotherapy in the following:
    1. Small lesion in lupus vulgaris and tuberculosis verrucosa cutis can be excised.
    2. Scrofuloderma: Reduces morbidity and total duration of chemotherapy.
    3. Plastic surgery is helpful in mutilating lupus vulgaris.
  6. BCG vaccination may be a double-edged sword:
    1. Its protective role is documented.
    2. Appearance of lupus vulgaris and tuberculides have been reported following vaccination.
    3. Owing to paucity of such adverse event vaccination is recommended.
  7. Cutaneous tuberculosis and HIV:
    1. Drug regimen is similar to non-HIV person.
    2. Treatment duration is increased to 9 month.
    3. Incidence of adverse drug reaction is increased.
  8. Multidrug resistance tuberculosis: Referral to specialized center.
  1. Identifying the underlying triggering factors, drugs like NSAIDs, etc. or food additives like preservatives, coloring agents or fragrances and to avoid it.57
  2. Determining the type of urticaria, physical, autoimmune, contact urticaria, delayed pressure urticaria, etc.
  3. Goal of the treatment:
    • Relieving the pruritus
    • Decreasing the size and number of lesions
  4. Nonsedative antihistamines
  5. Nonsedative antihistamines at morning and sedative antihistamines at night
  6. Nonsedative antihistamines at morning and antileukotrienes at night
  7. Doxepin 10 to 25 mg at night only in refracrtory urticaria
  8. Very short course of systemic steroids in very severe acute urticaria
  9. Sulfasalazine 1 to 1.5 gm or dapsone 100 mg daily for delayed pressure urticaria
  10. Dapsone in urticarial vasculitis
  11. Cyclosporin in severe refractory urticaria especially in autoimmune variety.
  12. In signs of acute breathing trouble or choking of throat immediate hospitalization in critical care unit.
  13. Danazol or stanzolol or C1 inhibitor concentrate in hereditary angioedema or acquire C1 inhibitor deficiency.
Initial evaluation should pinpoint the caliber of the predominantly involved blood vessel and the level of systemic involvement. Mainly the small vessel vasculitis group involving skin with or without systemic involvement is managed by dermatologist. There is no consensus management protocol. Following are the options:
  1. For cutaneous involvement only:
    1. General measures:
      1. Bed rest
      2. Avoidance of cold and prolong standing.
      3. Cause elimination: Withdrawal of suspected drug and treatment of infective focus.
    2. Pharmacological therapy
      1. H1 antihistamines
      2. Nonsteroidal anti-inflammatory drugs
      3. Colchicine
      4. Hydroxy chloroquine
      5. Pentoxifylline
      6. Dapsone58
    3. If no improvement, following drugs may be introduced.
      1. Systemic corticosteroid
      2. Azathioprine
      3. Cyclophosphamide
      4. Cyclosporine
      5. IVIG
      6. Plasmapheresis
        (Systemic corticosteroid is the preferred agent. Others are used in steroid unresponsive cases or when steroid needs to be stopped or reduced due to adverse effects.)
    4. For ulcerated lesion:
      1. Low dose weekly methotrexate
      2. Systemic steroid
      3. Thalidomide
  2. For systemic involvement step 3 drugs may be used from the beginning.
  1. Keratolytics: 5 to 20% salicylic acid, 17% salicylic acid, 17% lactic acid in flexible collodion
  2. Chemical cautery: 60 to 80% trichloroacetic acid (TCA)
  3. Light electrodessication and curettage
  4. Cryosurgery with liquid nitrogen
  5. CO2 laser or pulsed dye laser
  6. Imiquimod: Not much studied.
Limited Area
  1. Topical corticosteroids (class 3)
  2. Topical tacrolimus/pimecrolimus especially in facial lesions
  3. Topical paint PUVA/PUVA sol
  4. Topical bath PUVA
  5. UVB NB or PUVA in refractory lesions
  6. Skin grafting in stable, nonresponding localized lesions
  7. Covermark.59
Extensive Area
  1. UVB NB or PUVA
  2. Short course of systemic steroids: Only in rapidly spreading vitiligo in younger age group
  3. Sunscreen.