Best Practices

Context of the practice

Allergic contact dermatitis is commonly seen in clinical practice and finding the cause is essential to prevent recurrence.

Objectives of Practice

To provide patch test facility for confirmation of the aetiological factor in various eczematous and pigmentary skin diseases at affordable price

The Practice

Indian standard series, Hair dye series and Cosmetic series patch test kits are available at affordable prices for patients with allergic contact dermatitis, pigmented contact dermatitis and phtocontact dermatitis. All the patients with suspected ACD will be patch tested by applying equal quantity of the allergen on the back f the patient(uninvolved skin) and occluded using finn chambers followed by application of micropore tape. Results will be recorded at 48 hours (day 2) and 96 hours after application and graded as per guidelines by International Contact Dermatitis Research Group. The patches are removed after 48 hours . Then marking is done using a skin marking pen. After waiting for 15-20 min readings are taken.

Obstacles faced and strategies adopted to overcome them

Obstacle - Many patients are lost to followup as they need to come for patch test reading on 2nd, 4th and 7th day – the travel expenditure as well as time for repeat visits was the main issue

Strategy - Analyzing the readings using Teledermatology with Tripartite readings

Impact of the Practice

More than 700 patients have been patch tested at our department since then

Four thesis projects on patch testing have been completed at the department One project , which has received University Grant is ongoing

One publication in Web of science and scopus indexed journal Jasly K, Goyal S, Ashwini PK, Kanthraj GR, Chethana SG, Ranugha S. Three-part scoring system (tripartite) for teledermatology versus International Contact Dermatitis Research Group criteria to interpret patch test readings: A comparative observational study. Indian J Dermatol Venereol Leprol. doi: 10.25259/IJDVL_118_2023

Resources required

Patch testing was done for all the patients using the Indian standard series approved by the Contact and Occupational Dermatoses Forum of India (CODFI). The details of procurement of allergens were as follows: Manufacturer and supplier – Creative Diagnostic Medicare Pvt. Ltd., Mumbai, India; Dilution – 0.5%–100%; Vehicle – Petrolatum; Chambers – Aluminium; Application period – 48 h; Timings of readings – 48 th h, 96 th h and 7 day.

Financial support obtained from Indian association of dermatology, venereology and leprosy post graduates thesis grants 2022,academic encouragement provided by JSSAHER

Context of the practice

Vitiligo is a common skin condition, which is associated with significant impairment of quality of life of the patient. There are a subset of patients who fail to repigment or partially repigment and require surgery for repigmentation. Compared to cell cultuture NCECS is less time consuming and doesn’t require facilities for cell culture. Large areas can be covered with small size donor grafts at donor to recipient ratio of 1: 8 to 10, als it can be done for all areas.

Objectives of Practice

To provide latest vitiligo surgery procedurei.e Non-cultured epidermal cell suspension at affordable price to patients in need.

The Practice

Steps of the procedure

1. Harvesting the skin graft

2. Trypsinization and cell separation

3. Dermabrasion of the recipient(vitiligo ) site

4. Transfer and fixing of melanocyte rich cell suspension

Steps in obtaining epidermal noncultured cell sus-pension

  • Step 1: A split thickness thin graft is harvested under local/topical anesthesia
  • Step 2: Graft is placed in a Petri dish containing 5 mL of 0.2% trypsin +0.8% ethylenediaminetetraacetic acid (EDTA) solution
  • Step 3: Graft is soaked completely in the solution and spread out with epidermal surface facing upwards
  • Step 4: Incubated in an incubator at 37° for 45 minutes to 2 hours
  • Step 5: Trypsin solution is neutralized by 5 mL of 0.5% trypsin inhibitor Step 6: Dermis is teased out from the epidermis and discarded
  • Step 7: The cells are separated from the epidermis and transferred to a test tube
  • Step 8: The test tube with epidermal cells is centrifuged for 5 minutes to obtain a pellet rich in cells
  • Step 9: The pellet is resuspended in phosphate-buffered saline (PBS)/ Dulbecco's modified Eagle's medium (DMEM) and transferred to 1 mL tuberculin syringe, ready for application onto the recipient area

Obstacles faced and strategies adopted to overcome them

Obstacle

  • Many patients are lost to followup and fail to continue phototherapy post procedure
  • Displacement of dressing particularly on lips
  • Complex procedure requiring incubation at 37 degrees and centrifugation of the separated suspension
  • Trypsin inhibitor required for neutralization is very expensive. DMEM medium for resuspension of pellet is expensive

      • Strategy

      • Procurement of centrifugation machine for the department for easier centrifugation
      • Reminder calls and counselling of patients on phone regarding the importance of keeping dressing in situ as well as regular followup.
      • Using Phosphate buffered saline, patients’ own serum or Ringer lactate for neutralization instead of antitrypsin and DMEM

Impact of the Practice

Around 28 to 3o patients have undergone NCECS in the past 3 years of which more than 90% patients achieved more than 70% repigmentation 3-9 months post procedure

A research grant project done by department faculty on comparison of recipient site preparation with derm brasion versus fractional CO2 laser before grafting- under preparation for publication

A study is being undertaken by our postgraduate Dr.Tanmayi regarding patient satisfaction after all types of vitiligo surgery in our department

Resources required

Topical EMLA as well as Lignocaine injection, 0.2%Trypsin with 0.8%EDTA Petridish, Pippettes, Centrifuge tubes, Iris scissors, Jeweller’s forceps, Syringes, Sofratulle dressing, dynaplast, collagen dressing, hydroxymethyl cellulose gel Incubator, Centrifuge, electric or manual dermabrador