Credentialing as a Prescribing Psychologist in the Military: A Resource Manual Fairleigh Dickinson University M.S. Program in Clinical Psychopharmacology We are grateful to a number of individuals who contributed to the completion of this manual. The views expressed in this publication are those of the authors and do not reflect the official policy of position of the Department of the Army, Department of the Air Force, Department of the Navy, Department of Defense, Public Health Service, Indian Health Service, the United States Government, or any other agency for which the authors are employed. The final content is the sole responsibility of the Fairleigh Dickinson University M.S. Program in Clinical Psychopharmacology.
IaisdbulletinI SD IAISD Dr Dinesh Hawelia
Institute of Allergic & Immunologic Skin Diseases Dr Sukti Mukhopadhya 27/2C Bakultala Lane, Kasba, Kolkata-700042, West Bengal, India Dr Nilendu Sharma Dial :(033) 2442 8011 Dr Sanjib ChowdhuryDr Sudip Kr Ghosh Message from CODFI President
Derma-Allergologists: Role in Dermatological Care
Dr A K Bajaj, Allahabad
President, CODFI (Contact & Occupational Dermatoses Forum of India) Skin is an important immunological cutaneous drug reactions are the tertiary care centers, are over burdened organ and an open laboratory to study common allergic dermatological with the management of common skin in-vivo allergic reactions. Skin disorders accounting for a fairly large diseases. With industrialization and participates or shows manifestations of number of cases. Over and above tremendous change in the environment allergic/immune reactions taking place these common disorders vasculitis, the number of allergic disorder are in various internal organs or affecting panniculitis, non-eczematous contact going up. The need of the hour is only the skin. Such manifestations are reactions etc. also come under the establishment of specialized centers protean in nature and require perview of derma-allergologists. It is exclusively engaged in the study and Sherlokean approach or Dr. Watson s unfortunate that almost all the management of allergic disorders so keen eye and brain to critically analyze dermatologists (who are small in that these are adequately treated and or evaluate them. Contact dermatitis, number for an Indian population of cured where the removal of causative urticaria, atopic dermatitis and adverse billion plus), including those working in agent is possible. In a particular clinic the incidence of allergic contact dermatitis is determined by the interest the dermatologist takes
in allergic contact dermatitis.
Hjorth and Tregat
Can a Chemical Exposure in Localized Area
Lead to Generalized Vitiliginous Process?
Dr Sanjay Ghosh
We know that vitiligo originates as In some recent experiments this puzzle Cells with increased stress proteins are a u t o i m m u n e r e s p o n s e a g a i n s t has been attempted to be solved.
protected from consequences of melanocytes. However we are not 4-TBP (Tertiary butyl phenol), an subsequent stress. Released stress certain about which triggers this alternate substrate for tyrosinase, at proteins from the cells into the extra- autoimmune response and how this low concentration acts by competitive autoimmune process takes place. cellular milieu produce immune inhibition whereas at high concentration Recent research has emitted some as cytotoxic (not depending on the Contd to Page 4 Column 1 sharp light to visualize this misty zone in pigmentation of melanocytes). 4-TBP the pathogenesis of vitiligo.
Overexposure to UV rays, mechanical stress (burns, cuts, scratch) [Koebner's melanocytes which in turn releases phenomenon] and chemicals (phenolic stress protein HSP 70 (Heat Shock compounds & others) are known Protein). initiating factors of vitiligo. Can this local Stress proteins, also called induction lead to a generalized immune "Chaperokines", protect the cellular proteins from premature degeneration. Bulletin of IAISD
Management Strategy of Plaque Psoriasis
Dr Susmit Haldar
Psoriasis is a chronic inflammatory skin (topical superpotent corticosteroids) or should be diluted with petrolatum or disease as yet of unknown specific by combination (e.g. TCS +/- Salicylic used alternately with TCS. Other etiology. Like all other diseases of acid or TCS +/- Coal tar or TCS +/- Vitamin D3 analogues (calcitriol and unknown cause, various treatment Anthralin). If it fails, phototherapy or tacalcitol) are less irritating and thus modalities have been tried and systemic agents are required. The can be used in face and flexors. developed empirically in the past common practice is to combine Acitretin Tazarotene is too irritating for several decades and are continued to 25 mg daily with 'bath-PUVA'. Bath- intertriginous (crural) areas and should evolve till now. It is bewildering to PUVA is usually employed by soaking be avoided. It can be used effectively on choose an appropriate one among this the hands at first in a water-filled basin facial psoriasis if its use is restricted wide range of treatment options, unless with methoxsalen and then exposing to only for 1-5 minutes. Such a short a management strategy is followed. UVA irradiation. Other alternatives are contact period is found to be less The problem is further compounded by methotrexate or cyclosporine, which irritating on facial skin. Topical the fact that efficacy of many of these are claimed to be highly effective. calcineurin inhibitors (Tacrolimus 0.1% therapeutic agents or modalities are not ointment and Pimecrolimus 1% cream) tested by prospective, randomized, are used effectively Table 1. Management of localized psoriasis (< 5%)
double-blind, controlled studies. In general, the factors which are preferred for their important to remember in management safety and lack of side are: a) extent of involvement, b) areas effects on continuous of involvement, c) patient's perception use compared to even of the severity of the disease, d) low-potent TCS (Table patient's lifestyle, e) other associated health problems and medications, and Extensive Psoriasis
Topical Therapy TCS/ f) potential side-effects of the specific Vit. D3 Analogue/ (>5% BSA involve-
therapy planning to start. It is also equally important to realize that Topical therapy may not management of chronic psoriasis be adequate to control, needs individualization of therapy, even necessitating the use of after accepting the need of a strategic systemic agents or Conbination Thearpy Acitretin 25 mg/d + Bath PUVA approach. A management strategy is Class I TCS + Calcipotriol/ phototherapy. Manag- outlined below keeping a practical MTX or Cyclosporine ing all the lesions of approach in view.
Localized Psoriasis (<5% BSA Scalp
more than 10% BSA Mild involvement can be managed with only by topical therapy is impractical, Trunk and Extremities a tar-based shampoo twice or thrice but it can be a useful adjunct to other The treating physician has a choice of a weekly with or without TCS in lotion, treatment modality. UVB (BB-UVB) wide range of topical therapies such as gel, and foam formulations. Messy phototherapy is a preferred option to topical corticosteroids (TCS), Vitamin preparations like cream or ointments start with, especially for those patients D3 analogues (calcipotriol and others), are avoided for patients' dislike.
who respond well to sun exposure. If tazarotene, anthralin and coal tar. Severe scalp psoriasis, Efficacy of all these agents is endorsed manifested clinically Table 2. Management of localized psoriasis (scalp,
by various double blind, randomized, with very thick adherent face & intertriginous area)
controlled studies. When compared, scaly plaques, is each of these agents has advantages managed by using and disadvantages. For an example, keratolytic gel at night topical corticosteroids (TCS) are with TCS lotion during relatively more economic and devoid of Intertriginous Area day. Alternatively, an any local irritation if compared with ointment of oil of Cade calcipotriol (Vitamin D3 analogue), with Sulfur and Salicylic calcipotriol is free from the local side acid (in a ratio of TCS & Calcipotriol 20:10:5) can be applied (Night) + Steroid telangiectasia. The chance of rebound Tacalcitol (Face) and kept overnight and flare of healed plaque after withdrawal Oint. Of Oil of Cade Tazarotene (Face) cleaned with a Tar is virtually absent in case of calcipotriol shampoo next day. (20:10:5) (Night) Topical Tacrolimus compared to TCS. If a single agent fails steroid in Lotion/ + Tar Shampoo (Day) Steroid lotion can be to control psoriasis, the strategy will be +/– Steroid Lotion applied during daytime. a combination therapy of two agents (Table 2.) (e.g. calcipotriol or tazarotene can be failed, patients often respond to combined with superpotent TCS). Face and Intertriginous Area These areas respond very well to phototherapy. PUVA has proved itself to Palms and Soles (Only Plaque Type) various topical agents, but are very be one of the most effective treatments Psoriasis in these regions, though much prone to acquire the side effects. of psoriasis. As an increased risk of limited in extent, is disabling, Very low potent TCS is preferred to cutaneous malignancy is associated recalcitrant, and sometimes resistant to avoid the risk of atrophy, telangiectasia, with PUVA, it is usually kept reserved topical treatment. Strategy will be to try striae and erythema. Calcipotriol is also topically at first, either by monotherapy irritating and, if at all to be used, it Contd to Page 6 Column 1 Bulletin of IAISD
Lichenoid Contact Dermatitis
Dr Dinesh Hawelia
'Lichenoid ' is the term used clinically to LCD reported are musk ambrette, Dr Nilendu Sarma
describe a flat-topped,shiny,papular nickel etc.
eruption resembling lichen planus( LP) Histologically, features of LCD can be whereas histologically it connotes basal similar to that of LP. Certain histological 1. Allergic Contact Dermatitis to
cell liquefaction and a band-like features may help to diagnose lichenoid Herbal Cosmetics
inflammatory cell infiltrate in the contact dermatitis or lichenoid tissue Allergic contact dermatitis from a papillary dermis. Lichenoid contact reaction and they are as follows: focal natural deodorant: a report of 4 cases dermatitis(LCD) implies lichen planus- parakeratosis, focal hypogranulosis, associated with lichen acid mix allergy. like or lichenoid eruption resulting from greater degree of spongiosis, larger Sheu M, Simpson EL, Law SV, Storrs contact with various chemicals and number of necrotic keratinocytes and FJ J Am Acad Dermatol. 2006 Aug; cytoid bodies present higher in the 55(2) : 332-7. LCD may present with features typical stratum corneum and granulosum, Use of botanical ingredients in of classic lichen planus but papules are more pleomorphic cellular infiltrate, cosmetics and other personal care usually larger and scaly and they abundant plasma cells and eosinophils objects are thought to be safe and their resolve with post-inflammatory brown in infiltrate, deeper perivascular use are on rise worldwide. In this study pigmentation. Wickham's striae are infiltrate and less dense lymphocytic authors tried to evaluate the prevalence usually absent unlike classic LP and infiltrate which is not as band-like as in pattern of allergic sensitivity of a mucous membrane is less involved in specific botanical deodorant in 4 cutaneous LCD.Sometimes ,the Avoidance of contactants usually referred patients. Allergens found in all features of LCD may be atypical with localized or generalized eczematous Sometimes it may take many months acid. The lichen acid mix were already papules and plaques and variable for resolution. LCD should be established and common allergens in suspected if LP-like lesions are present USA. However botanical ingredients in Lichenoid contact dermatitis may occur in atypical distribution and possibility of deodorants were rarely the reported after contact with chemicals in colour exposure to contactants should be source till date. Important lacunae in the film developer. Lesions begin in areas explored. Allergic patch test may be study were the small sample size and of contact with the developer, but highly rewarding in suspicious cases to lack of specificity regarding the sometimes extend beyond the site of solve the puzzle.
importance of the individual lichens as contact.Lesions may persist for months the composite lichens were used. and usually resolve with post- Pinkus H. Lichenoid tissue reactions. 2 . R u b b e r A l l e r g y : W h i c h
inflammatory hyperpigmentation. Arch Dermatol 1973;107:840-6 Component Responsible ?
Substituted para-phenylene diamine 2. Schoel J, Tilgen W, Frosch RJ. Lichenoid (PPD)-A is usually responsible. Allergic contact eczema caused by colour film mercapto-mix: which should be in the patch test is positive to substituted developer. Hautarzt 1991;42:251-3 PPD-A and is usually eczematous in Chung WH, Chang YC, Yang LJ et al. Bruynzeel DP, Andersen KE, et al, nature. Temporary paint-on tattoos may Clinico pathological features of skin Contact Dermatitis. 2006 Jul; 55(1): lead to inflammatory skin reaction reaction to temporary tattoos and 36-8. which on histology shows lichenoid analysis of possible causes. Arch The European Environmental Contact dermatitis and allergic patch test is Dermatol 2002;138:88-92 Dermatitis Research Group (EECDRG) moderately to strongly positive to PPD Breathnach SM, Black MM, Lichen has conducted this study to analyze the (1% in petrolatum) and commercial planus and lichenoid disorders. In :Burns relevance of using Mercaptobenzo- T, Breathnach SM, Cox N et al. Eds. black henna.
Rook's text book of dermatology. 7th ed. thiazole (MBT) and mercapto-mix, both LP-like lesions have also been seen in Blackwell publishing, 2004;42.1-42.32 being rubber allergens in European persons exposed to dental restorative Lambo G, Belato N, Patruno C et al. standard series. This large multicenter materials, aminoglycoside antibiotics, Lichenoid contact dermatitis due to study on 32 475 consecutive tested metals such as mercury, silver and aminoglycoside antibiotic. patients among 11 centers in Europe gold. Oral mucosal LCD may be seen in Pigatto PD, Guzzi G, Persichina P. proved that they should continue to be persons coming in contact with dental Nummular lichenoid dermatitis from used simultaneously as omitting either mercury dental amalgam. Contact MBT or mercapto-mix from the Methacrylic acid esters used in car standard series will miss at least 20% or industry may lead to cutaneous LCD. Kawamura T, Fukada S, Ohtake N et al. 22% of positive cases respectively. As methacrylic acid esters are also Lichen planus-like contact dermatitis 3. Henna Dye : Chemical analysis
present in dental devices, oral mucosal due to methacrylic acid esters. Br J Quantification of para-phenylenedia- lichenoid dermatitis may also result.
Dermatol 1996;134:358-60 mine and heavy metals in henna dye. LP-like contact dermatitis in atypical 8. Kurada K, Hisanaga Y. The diagnosis of Kang IJ, Lee MH. Contact Dermatitis. distribution has been seen in persons lichen planus-like contact dermatitis to 2006 Jul; 55(1): 26-9. coming in contact with product chlorpheniramine maleate. Dermatology Henna (Lawsonia inermis, family containing chlorpheniramine maleate. Lythraceae) is a plant extract (dried leaf Colin-Chamley N, Canbier MP, Barhoun There is a case report of a papular extract) and is found in India, Sri Lanka K et al. Lichenoid contact dermatitis from erythematous pruritic lesion on back of the ink of a red pen. Ann Dermatol and North Africa. The active ingredient hand coming in contact with red inked or lawsone is structurally 2-hydroxy-1, pen writing. Other chemical inducers of 4-naphthoquinone. Sensitization potential of henna is extremely rare in comparison to PPD so it is used The greatest abuse of patch testing is failure to use the test.
Contd to Page 5 Column 1 Bulletin of IAISD
Cutaneous Adverse Reactions to Hypoglycemic Agents
Dr. Manas Sen
A) Sulphonylureas C) Insulin : Local reactions Arthus like reaction with 1) Chlorpropamide : maculopapular rash urticarial lesion at injection site; Steven-Johnson syndrome lipodystrophy with decreased adipose tissue at site of lichenoid eruption subcutancous injection exfoliative dermatitis : allergic skin rash, bullae Systemic reacting : urticaria, serum sickness like reaction : pruritus, erythema, urticaria, morbilliform rash, 1) Acarbose : erythema, exantheme, urticaria (rare) maculopapular eruption 2) Glucomanan/Guargum (food) : no skin adverse : allergic skin rash : exanthametous skin eruption 3) Nateglinide (non-sulfonylurea) : yet not found.
4) Pioglitazone (Thiazolidinedione) : yet not found.
5) Repaglinide (non-sulfonylurea) : rash 6) Rosiglitazone (Thiazolidinedione) : yet not found Can a Chemical Exposure in Localized Area
Lead to Generalized Vitiliginous Process?
From Page 1 response to the very cell from which untouched. DCs are equally capable of 4-TBP induced epidermal stress can lead killing stressed melanocytes to initiate they were derived. Thus extracellular an autoimmune response resulting in melanocytes by DC. This may instigate a stress proteins are not at all protective progressive depigmentation of skin. systemic autoimmune response to rather damaging for the cells! Stress Melanocytes exposed to 4-TBP show melanocytes when the same DC return to proteins can serve as antigens in elevated TRAIL death receptor draining lymph nodes, recruiting certain auto-immune diseases.Stress expression. TRAIL is a major player in melanocyte-reactive cytotoxic T cells to the DC-mediated cytotoxicity towards proteins also enhance an immune skin (Fig. 1).
stressed melanocytes. DC effector response by inducing phagocytosis & functions are partially inhibited by Source :
antigen processing by dendritic cells.
blocking antibodies to TRAIL. TRAIL 1. Kroll TM,Bommiasamy H, Boissy RE et al, HSP 70 induces TRAIL (TNF-related expression and infiltration by CD11c+ J Investigative Dermatology 2005; apoptosis-induced ligand) expression cells are abundant in perilesional 124:798-806.
and activates dendritic cells (DC) vitiligo skin.
2. Le Poole C, Yong F et al. J. Invest Derm. effector functions. Dendritic cells (DC) TRAIL expressing DC can be cytotoxic 1997, 113; 5:725-30.
can specifically kill tumor cells by towards stressed yet untransformed 3. Boissy RE, Marzu P. Pig Cell Res. 2004; leaving the surrounding healthy cells re tissue cells.
17 : 208-14.
Fig. 1. 4-TBP induces systemic vitiliginous process
4-TBP + Melanocyte Release of stress protein (Heat shock protein) (inadequate for protection) DC effector functions Systemic autoimmunity DC return to draining lymph node
Bulletin of IAISD
Autologous Serum Skin Test (ASST)
Dr Sudip Kumar Ghosh
3. Patient should not take immuno- 6. Weal and flare responses are to be One third of the patients of chronic suppressants within last 2 months measured after 30 minutes. Redness idiopathic urticaria have circulating 4. Ethical approval should be taken of weal and flare reactions is difficult functional autoantibodies against high from the appropriate body to perceive in pigmented skin types affinity IgE receptor.
5. Age should be 18 years or more (e.g. Indian skin). Autoantibodies in patients' serum can 6. Written consent from the patient or Criteria For Positive Response
be detected by serum induced
A positive test is defined as a red serum histamine release from the basophils of 7. Test area (usually forearms) should induced weal response with a diameter healthy donors utilizing methods : be free of lesions of 1.5 mm or more than that of the saline 1. ELISA, 2. Western blot assay.
induced response at 30 minutes. However, neither Western Blot nor ELISA can distinguish between Positive ASST denotes a subset of population who has an increased autoantibody from non-functional potential to develop urticaria due to autoantibody. Moreover, these tests are endogenous causes than do patients done in some specialized centers only without a positive test. The significance as well as time consuming to perform.
of a negative test remains unclear.
So a rapid and reliable clinical test to differentiate between patients with or 1. Hide M, Francis DM, GrattanCEH etal, Autoantibodies against the high affinity autoantibodies would be of value in IgE receptors cause of histamine release initiating or evaluating the efficacy of in chronic urticaria. N.Engl J Med 1993; Causes of False Positive Results
Weal and flare response can be 1. Variations in injection technique e.g. 2. Fiebiger E, Hammerschmid F, Stingl G et induced by the intradermal injection of depth or volume of injections.
al. AntiFc RI autoantibodies in autologous serum in some patients. 2. Dermographic subjects These observations lead to the Procedure
Identification of a structure-function identification of circulating autoanti- 1. 2ml venous blood taken from relationship. J Clin Invest 1998; 101:243- bodies in chronic idiopathic urticaria and provides the basis of autologous 2. Blood is allowed to undergo clotting 3. Nimi N, Francis DM, Kermani F et al. serum skin test (ASST).
at room temperature.
Dermal mast cell activation by Sensitivity of ASST ranges between 3. Serum is separated by centri- autoantibodies against the high affinity 65% to 71% and specificity between IgE receptor in chronic urticaria. J Invest Dermatology 1996; 106:1001-6 Indications
intradermally into the volar aspect of 4. Sabroe RA, Grattan CEH, Francis DM et Suspected cases of autoimmune forearm,avoiding the areas of al. The autlogous serum skin test: a wealing happened within the past 24 screening test for autoantibodies in chronic idiopathic urticaria. Br.J. 1. Withdrawal of antihistamines at least 5. Similar amount of normal saline is Dermatol 1999; 140:446-52 2-3 days prior to the test injected intradermally distance from 5. Grattan C.E.H. Autoimmune urticaria. 2. Doxepin and astemizole should be saline injection site 3-5 cm at in the Immunol Allergy Clin N Am 24 (2004) 163- withdrawn 2-6 weeks beforehand volar aspect of the same forearm.
Recent Research : Contact Dermatitis & Urticaria
From Page 3
extensively in different parts of world and epoxy resin: a prospective It was intended to examine the including Korea. Rare occurrence of multicentre investigation of the incidence and etiology of late phase allergic reactions could be due to the German Contact Dermatitis Research reaction of Para-phenylenediamine (PPD-1% pet) and epoxy resins (ER- chemical itself. However this Korean 1% pet) among 1748 patients and study found presence of impurities like Hillen U, Jappe U, Frosch PJ, et al Br nickel sulphate (5% pet.) among 812 PPD or some heavy metals like nickel, J Dermatol. 2006 Apr;154(4):665-70. patients. Surprisingly late reactions cobalt, chromium, lead and mercury Late phase reaction on or after day 7 were not seen with nickel sulphate in could in different samples of henna. It has been reported after many any of the patients. A high percentage was interesting to find the presence of allergens. However its reason is still of patients produced elicited late PPD, nickel and cobalt were detected in 3, 11 and 4 samples among 15 henna sensitization is one of the theories. etiology was patch-test sensitization. Authors report the trial result of a The group made a drastic step based on the study report to stop this 4. PPD : Late Phase Reaction
prospective multicentre investigation Late reactions to the patch-test by the German Contact Dermatitis sensitization by de-listing the PPD 1% preparations para-phenylenediamine Contd to Page 7 Column 2
Bulletin of IAISD
Dr. Sukti Mukhopadhyay
Both the sides are marked acordingly Table 1. Common photoallergens
Photopatch test is an useful tool to with the marker pen.
A. Sunscreen chemical noted. Offending allergens causing 1. Para-aminobenzoic Acid (PABA) photocontact dermitis or allergic 2. Padimate O & A Patients with eczematous eruption contact dermatitis are identified.
predominantly affecting light exposed Post-photo patch test counselling is sites and in whom a history of done and the patients are then given worsening following such exposure Time Period
B. Fragrance Ingredtients Patient has to come thrice to the physician. On the 1st day (0), 2nd day (after 24 hrs.) and 4th days (after 72 2. 6-Methyl coumarin 3. Sandalwood oil Method
1st day : Initially, a portion of the lower
C. Antibacterial agents back portion of the patient is marked and exposed to UVA light at a dose of 2. Hexachlorphene 3. Halogenated salicylanilides The test site, usually the upper back portion is selected, where the photo D. Miscellaneous compounds allergens, in two sets, are placed on 1. Patients own product both sides. The common photo instructions to avoid individual allergens (Table 1) with control are allergens accordingly.
applied by Finn chambers.
2nd day : The patch on the left side is 4. Chlorpromazine Same as in patch test.
removed and the patch test reading is 5. Diphenhydramine Photopatch test is otherwise a very safe 6. Hydrocortisone The right side (non irradiated side) is test. The test is not done in patients then covered with an opaque dark suffering of SLE.
The left side is the exposed to UVA light 1. British photodermatology group : 9. Paraphenylediamine at a dose of 4J/cm . (irradiated side).
Workshop Report Photopatch Testing E. Plants The patch on the right side is then methods and indication, Brit J Dermatol, 1. Parthenium hystorophorus 1997; 136 : 371-6.
Education in the technique of patch testing is as essential to physicians in training as the learning of most
Management Strategy of Plaque Psoriasis
From Page 2
achieve adequate remission to both BB- Biologics : Recent strategic position studies and are recommended in the
UVB and NB-UVB phototherapy. If in management
management. However, the prohibitive PUVA or phototherapy fails to achieve In recent years, an extensive research cost may limit their use and the long- satisfactory result, low dose acitretin on pathogenesis-based treatment of term safety of these agents is not (10-25 mg. daily) can be added to obtain psoriasis has developed producing a known. Presently, expert's opinion is improved response to UVB and to number of agents popularly named as divided distinctly in two groups. Some PUVA. In patients in whom UVB 'Biologics'. Alefacept (antibody against are in opinion to use biologics as a first T-lymphocyte surface molecule), contraindicated, methotrexate alone or line therapy where the disease is too combined with other treatments or Efalizumab (antibody against adhesion extensive to manage by topical agents, Cyclosporine is highly effective option. molecule), Infliximab and Etanercept while others, because of high cost,However, a close monitoring of the toxic (Anti-TNF alpha agents) are the agents want to try biologics only after trialside effects of both these agents is showing their efficacy in prospective, of phototherapy or other systemic mandatory. ( Table 3) randomized, double-blind, controlled t's agents.
Contd to Page 7 Column 1 Bulletin of IAISD
Management Strategy of Plaque Psoriasis
From Page 6
Other Strategic Concepts
Combination Therapy is also important to know the Rotational Therapy The goal of combination therapy is to 'contraindicated' combinations, as the The primary aim of the rotational achieve enhanced clinical response risk of toxicity or side-effects of one therapy is to minimize the cumulative and to reduce the side effects of each agent is increased in presence of other toxicity of each of individual form of (e.g. accumulation of cyclosporine and therapy. Thus, for example, the risk of thus its increased toxicity can be seen carcinogenesis of PUVA, hepatic Table 4. Contraindicated Combinations
when acitretin is combined) (Table 4).
fibrosis and need for liver biopsy with methotrexate and the musculoskeletal Sequential Therapy toxicity of retinoids can be minimized if The aim is to clear psoriasis by potent these three forms of treatment are used agent initially and then to maintain remission by safer, less effective Table 3. Management of extensive
agents. As for an example, cyclosporine psoriasis (> 5%)
is used initially to clear psoriasis and Cutaneous Malignancy retinoids + UVB is used subsequently for maintenance.
Cutaneous Malignancy 1. Christophers E, Mroweitz U.Psoriasis.In: Freedberg IM, Eisen AZ, Wolff K, et al, eds. Topical Therapies Fitzpatrick's Dermatology in General Medicine.vol.1, 6th ed. New York: McGraw Hill, 2003: 407- 27.
If no adequate remission 2. Lebwohl MG, Kerkhof PCM. Psoriasis. In: agent often by reducing the individual Lebwohl MG, Heymann WR, Berth-Jones J, If Contrindicated dose in comparison to the treatment by Coulson I, eds.Treatment of Skin Disease- them separately as monotherapy. If no satisfactory result Comprehensive Therapeutic Strategies. 2nd Various topical agents are combined ed. Philadelphia, USA: Mosby, 2006: 550-59.
among themselves (e.g. calcipotriol + Acitretin 10-25 mg daily + UVB/PUVA superpotent TCS) or with phototherapy/ Dermatologic Therapeutics with Essentials in rotation. The different treatments photochemotherapy (e.g. calcipotriol + of Diagnosis. 6th ed. Philadelphia, USA: used in rotational therapy are PUVA, tar + phototherapy) or systemic Lippincott Williams & Wilkins, 2002: 173-184.
determined by patient response. Since therapies (calcipotriol + acitretin). 4. Kerkhof PCM.Psoriasis.In: Bolognia JL, biologics are not found to be associated Phototherapy/ photochemotherapy and Jorizzo JL, Rapini RP, et al, eds. with major organ toxicity, their long-term retinoids (UVB + retinoids; PUVA + Dermatology, vol.1, 1st ed. London : Mosby, use obviates the need for rotation.
retinoids) are also used effectively. Itnt Recent Research : Contact Dermatitis & Urticaria
From Page 5 pet from the standard patch test compared its efficacy for this purpose Dreskin SC, Efaw B, J Allergy Clin series. with HR assay by ELISA, serum levels Immunol. 2006; 117(6):1430-4. 5. Auto-immune Urticaria : Search
for Biochemical Markers
of soluble CD40 ligand (sCD40L) and CD203c expression on basophil by the a. Szegedi A, Irinyi B, Gal M et al, also the ASST. Basophils were obtained sera of patients with CU was assessed by Significant correlation between the from atopic (DA) and a nonatopic (DNA) flow cytometry and the relationship CD63 assay and the histamine release donor and serum taken from of 72 examined between the size of ASST, a assay in chronic urticaria. Brit J Dermat patients with CU. Twenty normal people clinical parameter and level of CD203c 2006; 55(1):67-75 and 26 patients with systemic expression. Results showed that patients Autoimmune urticaria is a newly coined autoimmune diseases served as with CU and positive ASST had a subset of chronic urticaria (CU) based significant upregulation of CD203c. There control. CD63 expression was found on the development of wheal and flare was also a significant clinicomolecular unregulated in 57% of DA and 28% of correlation between the size of ASST and reaction in simple clinical test called DNA. Authors concluded mentioning level of CD203c expression.
autologous serum skin test (ASST). In that the CD63 expression assay was a search of a reliable and confirmatory reliable functional test in the diagnosis test authors developed a new method of ACU especially when basophils were Articles are invited from dermatologists of CD63 expression assay by flow obtained from suitable donors.
and other physicians regarding various cytometry as a marker of serum- facets of allergic and immunologic skin b. Chronic urticaria sera increase basophil diseases for contribution in this bulletin.
induced basophil activation and CD203c expression Yasnowsky KM, – Editorial Team
Bulletin of IAISD
IAISD NEWS 2005-2006
Celebration of World Allergy Day by IAISD on 8th July 2005 at Rotary Sadan, Kolkata involving dermatologists, chest specialist Simultaneously from Industrial and
and allergologists of Kolkata and surroundings.
Personal Sources Causing Allergic
a) Prof A K Bajaj, Ex-National President of IADVL and eminent derma-allergologist of Contact Dermatitis of Hands
International repute delivered ‘Mr Sukumar Ghosh Memorial Lecture' on chronic urticuria.
Dr Sanjib Chowdhury
b) Eminent dermatologists of the State took part in a panel discussion on ‘Derma- Allergy'. found positive were : (1) Paraphe- c) Consultant dermatologists from IAISD nylene diamine (PPD) 1+ (2) Personal presented an audio-visual symposium on Many cases of hand dermatitis hair dye brand used by patient 3+.
‘Contact dermatitis' originate from contract dermatitis The patient was advised to hold the Inter-displinary and intra-disciplinary among which irritant contact dermatitis in-house seminars : outnumbers allergic contact dermatitis. personal hair dye strictly and managed a) Psoriatic arthritis (among rheumato-logists, Allergic patch test remains the only by potent topical steroid, antihistamine orthopedicians and dermatologists).
sure dignostic tool to differentiate b) Chicken pox (among physicians, pediatri- between the two forms of contact cians and dermatologists).
dermatitis. Results of patch test should c) Epidemiology & statistics of skin diseases be properly interpretated in the light of (among epidemiologists and dermato- information obtained from the pre- and post-patch test counselling of the d) Photodermatology (among dermatologists) patient. Various sources of the e) Contact dermatitis (among dermatologists) identified allergens should be f) Urticaria (among dermatologists) highlighted to the patients for strict avidence in future.
l Scientific papers/Invited lectures from IAISD Case Report
and using gloves during works. Even accepted in the following conferences : A male patient aged 47 years reported after 1 month the patient did not get a) Asian Congress of Dermatology, 2005, at Institute of Allergic and Immunologic appreciable improvement. Hence he Kualalampur (Guest Lecture) Skin Institute, Kolkata with itchy scaly b) Asia-Pacific Environment & Occupation was advised to strictly avoid his rash over the finger tips (thumb, index, Dermatology Symposium 2005, Manila hydraulic oil exposure. After one ring) of both hands as well as over c) National Seminar on Pollution in Urban month the patient get considerable palmar aspect. The lesions had Industrial Environment Kolkata 2005 developed about a year back. Painful crevices were also present over the d) State conferences of Dermatology, Goldcon, Cuticon 2005, Kolkata (awarded finger tips. He was employed at the Apart from hair dye, the allergen 'ORE & coat berth Division at Port paraphenylenediamine is present in e) National conference of AIDS & STD, 2005 where exposure to hydraulic oil is quite grease, mechanical oil, permanent common. He had history of using hair hair, dye, rubber, plastic. He was f) Zonal conference of Dermatology, dye for last 2 year.
advised to avoid the above allergens Dermozone 2005, Guahati.
On examination he had papulosqua- strictly, which ultimately solved the g) National conference of Dermatology, mous plaque lesions over the index problem. Thus avoidance of all this Dermacon 2006, Hyderabad (5 papers).
finger, ring finger and thumb of both sources of identified allergens became h) Fungal Diseases : An Update – A Multi hands. A few discrete erythematous essential for proper management of the disciplinary seminar organised by Institute of papular eruptions appeared over the dermatitis. Hence in the pre- and post- Pulmocare and Research, Kolkata, 2006.
palm. Other test counselling of the patients about all areas of body this possible sources of allergens both were spared. industrial exposure as well as personal l Free skin check up camp at Industrial area of R o u t i n e sources should be explored for out and Budge Budge (in collaboration with the out avoidance.
Budge Budge College) l Free School health camp (at Kamala normal limits, Conclusion
Chattergee School for Girls, Kolkata) i n c l u d i n g Paraphenylene diamine (PPD), an l Free Skin Camp at IAISD premises scraping for fungus which was important and common allergen negative. Systemic examination did causing allergic contact dermatitis can l Social awareness programme : not reveal anything.
origin from personal usage source as mInvitation for essay competition among well as industrial or occupational students from different schools of Kolkata on Previous topical steroid applications, sources.
‘environmental pollution'. Three students as advised by previous doctors, was awarded best prizes as recommended by a stopped for 7 days and then patch test pannel of judges comprising of eminent using Indian standard battery of 1. Ket NS, Leok GC. The principles and writer, critic and teacher.
allergens as designed by CODFI practice of contact and Occupational mParticipating in ‘Ananda Mela' arranged by (Contact & Occupational Dermatoses Dermatology in the Asia-Pacific Region. Presidency Girls' Educational Society for Forum of India) and the brand of dye New Jersey : World Scientic 2001; 47- display of poster negating myth on skin used by patient. Readings were taken after 24 hours and 72 hours 2. Meaks JG, Elisner P, Deleo V. Contact mPublication of books in ‘Bengali' on ‘Contact and Occupational Dermatology, 3rd Ed. respectively. The allergens which were dermatitis' and vitiliginous for patients.
London Mosley, 2002, 117-9.
Published by Mrs. Shrabani Ghosh on behalf of Institute of Allergic and Immunologic Skin Diseases (IAISD), 27/2C, Bakultala Lane, Kasba, Kolkata-700042 and printed by Subhrajyoti Bose, 4B, Dharmatala Road, Kolkata-700039
Mixed Methods Research Designs: Applications to Public Health Stephen Lankenau, PhD École des hautes études en santé publique April 11, 2013 • Grant support from the National Institute on Drug Abuse: R01 DA015631; R01 DA021299; R21 DA026789. • Colleagues, staff, and students at Drexel University, University of Southern