Prelims

What Exactly is Dandruff?

Rama Murthy DVSB MD Professor and Head Department of Dermatology, Venereology, and Leprosy Katuri Medical College Chinakondrupadu Guntur District, Andhra Pradesh, India Foreword IS Reddy

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What Exactly is Dandruff? / Rama Murthy DVSB

First Edition: 2021

9789351522379

Printed at

The Supreme Biotechnologist

Lord SHIRDI SAI BABA

The Man behind Triggering Pathogenic Mechanism of Psoriasis Heinrich Koebner(1838–1904)

Foreword

The two in one monograph titled “What Exactly is Dandruff?” and “South Indian's Foot: A Storehouse of Diagnostic Clues for Psoriasis” authored by senior and eminent dermatologist Professor Rama Murthy DVSB, though a tad audacious, is very interesting and thought provoking. These monographs are the culmination of the focused and scholarly observations of the author extended well over the period of three decades.

The author's statement “Looking beyond the skin lesions and also looking beyond the patient” emphasizes the importance of the role of history taking and through clinical examination. The author's inference that pityriasis capitis, seborrheic dermatitis, and psoriasis belong to the same spectrum of a disease process, i.e., the first and second entities are nothing but psoriasis is debatable and may raise many eyebrows. The author made a sincere attempt to prove his point. The author's claim that lack of granular cell layer in psoriasis is the cause for the early skin changes that need further corroboration.

As it is mentioned in these monographs, the standard textbooks of dermatology include pitting, onycholysis, and salmon patches (oil drops) as the usual nail changes are observed in psoriasis. The author deserves a lot of accolades for bringing out so many hitherto unreported nail changes such as “angulation, overcurvature, melanonychia, etc.” A special emphasis is laid to examine the toenails in addition to fingernails. The clinical photographs, especially that of various types of nail changes, are so vivid and of high quality. The references are extensive and up-to-date.

In these monographs, Professor Rama Murthy DVSB presented his clinical observations, newer concepts based on these observations, and his arguments to support these concepts. Most of these observations were supported by high quality images. Though the author presented his views, it is up to the reader to reflect, evaluate, and validate them. I am confident that these monographs will kindle lot of interest in both younger as well as senior dermatologists.

IS Reddy MD DD DNB

Consultant Dermatologist Apollo Hospitals, Jubilee Hills Hyderabad, Telangana, India

Preface

I would first like to pay my humble pranam to the creator of this universe and the supreme biotechnologist, Lord Shirdi Sai Baba, and to my beloved patients without whose blessings and co-operation this book would not have seen the light of the day.

This book titled “What Exactly is Dandruff?” is, in fact, a combination of two monographs. The title of second monograph is “South Indian's Foot: A Storehouse of Diagnostic Clues for Psoriasis.” While the former deals with how the author identified the exact etiology of dandruff, while dealing with scaling scalps over the last 3.2 decades, the later deals with the amazing creation of clues to psoriasis which HE asked the feet to store and display when wanted by a dermatologist.

According to overseas literature, psoriasis is characterized by well-defined erythematous plaques covered with silvery white scales. Many variants have also been described with typical features; meaning that psoriasis and its variants can be diagnosed clinically itself with ease. Some fingernail changes have also been described which enable a dermatologist to diagnose nail psoriasis (only) in unequivocal terms. In case of any doubt, biopsy is recommended which may either confirm or rule out psoriasis.

Against this backdrop, why Rama Murthy DVSB, a nonentity in the world's arena of dermatology including in his own country, ventures to author a book titled “What Exactly is Dandruff?”

The first reason is that psoriasis in this region does not generally conform to the Western literature including those who are as fair as Caucasians; it is in winter that occasionally does one present with so-called “typical morphology.”

The second reason is psoriasis expresses itself in different morphological forms at different locations in the same individual; these expressions include excoriated papules, miliaria rubra-like lesions, subacute eczematous to lichenoid plaques, lichenoid papules, prurigo nodularis-like lesions, keratolysis exfoliativa-like lesions, pompholyx-like picture, autosensitization dermatitis, and may present as various forms of dermatitis, involving any part of the body, which do not fit into any known endogenous eczema, or may mimic any known eczema either exogenous or endogenous and may mimic even scabies by presenting as acute prurigo, in particular, in winter season.

This is my experience/clinical observation over the last 3.2 decades. Hence, my hunt for clues began. In the process, what I realized is the beauty of art of examining a skin patient lies in looking beyond the lesions that are initially shown to the dermatologist by the patient. After some time, I also realized that psoriasis being a genetically inherited disease, one (dermatologist) must look beyond the patient, i.e., any genetically-related individual accompanying the patient. If any member of the pedigree accompanying the patient displays psoriasis or gives history of psoriasis or gives history of psoriasis in his family, the patient's clinical presentation should be interpreted against this backdrop.

Thus, I learned many lessons from many patients who include patients from all Southern states of India (Guntur is almost a small cosmopolitan city).

Another invaluable lesson I learnt is not to expect our histopathologists to come to our rescue for diagnosing puzzling presentations of common dermatoses (which should be diagnosed clinically by the dermatologist himself or herself). Perhaps, it is not nice to depend upon/trouble our histopathologists, in this regard, and finally throw blame on them that they have failed to come to our rescue. What I mean to say is that a histopathologist can be relied upon in respect of rare dermatoses such as tumors, etc.

The creator is mischievous in the sense that HE creates a tricky presentation and HE, being very generous and kind to the mankind, keeps clues in hidden or far away regions. The feet are the most distant acral parts of the human body. These clues should be relied upon, only when no other etiology is found for the presenting, tricky dermatitis, in question.

HE has been kind to me; therefore, I could focus on feet for the last 1.5 decades and on scaling scalp, hence this book.

I have touched upon a part of the body that has been, hitherto, missed by Caucasian researchers/authors. I am given to understand that the dermatologists in cosmopolitan cities and in peripheries too of my country are simply at all rather blindly getting carried away by (in spite of our huge patient bank as against the Caucasian's patient bank) overseas literature that emerges from a small volume of clinical material that forces them to depend on various investigations, perhaps, which are more of commercial value.

I hope this book would inspire practicing dermatologists with rich clinical experience across the country, to speak out their mind in their respective areas of interest, and, thus, contribute to enriching clinical dermatology—Indian perspective.

Rama Murthy DVSB MD

Email: dvsbrm@gmail.com

Acknowledgments

Patients, undoubtedly, constitute the backbone for clinical research. I am fortunate that I am an Indian and teaching/practicing dermatologist in a country like India, wherein, even today, doctors are considered equal to God by the patients to whom I am indebted and I bow my head as a mark of respect to all of them.

There is a big list of individuals who helped me technically and otherwise, to whom I should extend my sincere gratitude. Some of them whom I can never forget in my lifetime include Mr Debasish Haldar, Mr Tanuja Prasad, Mr Srinivas (Medical Photographer), Mr Durga Prasad, Mr Venugopal, and the medical team at Jaypee Brothers Medical Publishers (P) Ltd, New Delhi.

My thanksgiving will not be complete without mentioning Shri Jitendar P Vij (Group Chairman), Dr Richa Saxena (Associate Director, Professional Publishing) and Himani Pandey (Development Editor) at Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, who helped me in publishing this book so nicely.

I am thrilled by the dynamism of the CAPTAIN and his team of CANIXA, for sponsoring this book, and I am indebted to CANIXA.

I cannot but express my sincere gratitude to Dr IS Reddy for having written a ‘book review’ like foreword, sparing his invaluable time for this.

List of Abbreviations

What Exactly is Dandruff?

V Dsq :

Visible Desquamation

(R) GTN :

Right Great Toenail

(L) GTN :

Left Great Toenail

HK :

Hyperkeratosis

APMCE :

As Per My Clinical Experience

SD :

Seborrheic Dermatitis

Psv :

Psoriasis Vulgaris

RSL :

Robust Scientific Logic

TNs :

Toenails

SCPC :

Subclinical Psoriasis Capitis

RAN :

Retro Ala Nasi

(R) RETRO.AUR.AREA :

Right Retroauricular Area

(L) RETRO.AUR.AREA :

Left Retroauricular Area

SUHK :

Subungual Hyperkeratosis

ABCD :

Airborne Contact Dermatitis

G Father :

Grandfather

MG Father :

Maternal Grandfather

MA :

Masquerading As

PPP :

Palmoplantar Psoriasis

EAC :

External Auditory Canal

SM Region :

Submental Region

RN Fold :

Retronasal Fold

PD :

Photodistribution

South Indian's Foot: A Storehouse of Diagnostic Clues For Psoriasis

TDP :

Terminal Differentiation Program

CE :

Cornified Envelope

CLE :

Cornified Lipid Envelope

PKC :

Protein Kinase C Family

BMZ :

Basement Membrane Zone

DEJ :

Dermoepidermal Junction

TASC :

Transit-amplifying Stem Cells

Dsg :

Desmoglein

Dsc :

Desmocollin

Pkp :

Plakophilin

HK :

Hyperkeratosis/Hyperkeratotic

GT/s :

Great Toe/s

PNF :

Proximal Nail Folds

LNF :

Lateral Nail Fold

ONL :

Onycholysis

KLN :

Koilonychia

MLN :

Melanonychia

SUHK :

Subungual Hyperkeratosis

LND :

Lateral Nail Dystrophy

CLC :

Cave-like Curvature

LTN :

Little Toenail

TN :

Toenail

GTN :

Great Toenail

DSE :

Dome-shaped Elevation

Chapter Notes