Vitiligo — a social stigma
Dr Gurinderjit Singh

Vitiligo is a pigmentation disorder in which melanocytes (the cells that make pigment in our skin) are destroyed. As a result, white patches appear on the skin in different parts of the body. Patches may also appear on the mucous membranes (tissues that line the inside of the mouth and the nose) and the retina. Sometimes the hair that grows on the area affected by vitiligo turns white. Vitiligo is not a disease as no pain and no specific symptoms are found associated with it.

The cause of vitiligo is also not known, but doctors and researchers have several different theories. There is strong evidence that people with vitiligo inherit certain genes that make them susceptible to depigmentation. However, the most widely accepted view is that depigmentation occurs because vitiligo is an autoimmune disease — a disease in which a person’s immune system reacts against the body’s own organs or tissues. These autoimmune diseases include hyperthyroidism (an overactive thyroid gland), adrenocortical insufficiency (the adrenal gland does not produce enough of the hormone called corticosteroid), alopecia areata (patches of baldness) and pernicious anaemia (a low level of red blood cells caused by the failure of the body to absorb vitamin B12) and it is most common in people with thyroid disorders. The exact reasons for the association between vitiligo and these autoimmune diseases are yet not known.

Vitiligo and leucoderma are used synonymously most of the time, but both are different. Vitiligo is an autoimmune 
disease of unknown origin, while leukoderma is a collective term applied to the skin condition in which depigmentation occurs following some inflammatory injury to the skin.

There is a general feeling that vitiligo has no cure. Michael Jackson was first diagnosed during the time he released his “Off the Wall” album, in the mid-1970s. Treatments were still being developed and the awareness of the disease was not there. So naturally, the only solution for Michael then was to cover it up using cosmetics.

Vitiligo is neither contagious nor harmful medically, yet its emotional and psychological effects can be devastating. Regardless of a person’s race and culture, white patches of vitiligo can affect 
emotional and psychological well-being and self-esteem.

Management of vitiligo

Most patients expect quick results. Whatever treatment is recommended, they feel disappointed. When the condition shows no quick response they change the doctor. It is essential for the patients to know that malanocytes are slow responders to any form of therapy currently available. Treatment may have to be continued up to 12 months or even more for an optimal response. The melanocytes are totally absent in the depigmented area. They have to be coaxed from the edge of the lesion or from the reservoir in the hair follicle to migrate. That is why the hairless areas of the body such as eyelids, palms and fingertips respond to the treatment poorly. The hair when white is an indication of the depletion of the reservoir of pigment 
cells. Such lesions respond to the 
treatment poorly.

Surgical treatment

Various surgical modalities have brought a revolution as far as the treatment of vitiligo is concerned. Some of the latest innovations are surgical excision, dermabrasion, micro-pigmentation (tattooing), punch grafting, thin thiersch graft (split thickness skin graft), epidermal grafting by suction blistering and repigmentation with cultured melanocytes.

The writer is Chief Dermatologist, Mohan Dai Oswal Cancer Treatment & Research Foundation, Ludhiana. E-mail: gursheen@satyam.net.in

Meniscus injury common cause of knee pain
Dr Ravinder Chadha

Individuals afflicted by knee arthritis sometimes, without any warning, experience pain on the inner side of the knee without injury or any other cause. This is due to the degeneration of the meniscus with aging. With aging, the meniscus shrinks, becomes desiccated and shrivelled, rendering it more susceptible to injury. Degenerated meniscus is akin to a rubber band when left out in the sun.

The knee joint has two semi-lunar cartilage menisci. These lie on the inner and outer edges of the upper surface of the shin bone. These act as shock absorbers for the knee, thus allowing appropriate weight distribution between the tibia and the femur (thigh bone). Injuries to meniscus can lead to the impairment of the knee functioning.

Medial meniscus is more prone to injury as it is connected to the joint capsule and so is less mobile as compared to lateral meniscus. Any injury impacting on the outer surface of the knee can severely damage the medial meniscus.

Longitudinal tears heal faster than radial tear due to better blood supply. In severe cases, a portion of the meniscus becomes detached from the tibia forming a flap that looks like a bucket handle.

Symptoms

l Pain on the inner side of the knee joint
l Swelling of the knee joint.
l Difficulty in bending the knee.
l May be, associated with a clicking sound.
l “Locking” of the knee, especially when extending from a bent position.
l Inability to bear weight on the affected side.

Conservative treatment is preferred in the case of a small tear whether due to injury/degeneration. This is as follows:

l Medication to alleviate pain.
l Electrotherapies vis-a-vis ultrasound, TENS, etc.
l Knee support.
l Once pain has subsided, exercises facilitate the range of motion and balance.

Exercises

l Sitting with the back against the wall, bending one leg and raising the other straight a few inches above the ground. Holding for a count of 10, lowering slowly and relaxing for a count of five. Repeat this 10 times.

l Lying on the back, placing a pillow under the knee. Push the knee downwards. Repeat this 10 times.

l Stretch-band exercises are very safe and strengthen the muscles. Lying on the back, tie a stretch band around the ankle. Raise the affected leg upwards, return back. Repeat 10 times

l Lying on the stomach, put a stretch-band on the ankle and bend the lower leg, returning back slowly. Repeat 10 times.

Surgery

The aim of surgery is to preserve as much of the meniscus cartilage as possible. In case conservative management fails, then trimming a meniscus (partial meniscectomy) relieves pain and locking, allowing a normal range of activity. Arthroscopic surgery is done in severe meniscus tears (buckle handle tear).

Success of the surgical procedure depends not only on the severity of the tear but also on the age and physical condition of the patient. Younger and fitter individuals are generally assured of a better outcome. Total menisectomy causes 50 per cent reductions in load, 20 per cent reduction in shock absorption capacity and knee bending up to 60 per cent. A post-surgery rehabilitation exercise programme which envisages stretching, strengthening and balance training are mandatory. In minor (meniscus) injuries, a well cocoordinated, comprehensive rehabilitation programme based on the individuals need is the key to successful and complete recovery.

The writer runs a pain management clinic in Chandigarh. E-mail: chadha_r2003@yahoo.co.in

ABC of diabetes management
Dr K.P. Singh

When the person with diabetes is diagnosed and assessed, the management should start with the patient’s education and lifestyle modification which is continued for two to three months. Consequently, HbA1c evaluation is undertaken. If the HbA1c level achieved is < 7 per cent then this regimen should continue.

If, however, the desired HbA1c level is not achieved then the next step is to introduce anti-diabetic drug therapy. It may of interest to know that the mere patient’s education and lifestyle modification have shown significant improvements in blood sugar control (reduction of HbA1c 0.8 to 1 per cent) as well as improvement in the control of weight loss, control of blood lipid and blood pressure with a reduction in the complications of diabetes. Thus, self-education and lifestyle modification is of prime importance in diabetes management.

The diabetes management team — which includes nurses, dietitians, mental health professionals, etc — should discuss the diabetes management plan with the patients and/or the family members on following lines: Describing the diabetes disease process and treatment options; incorporating nutritional management into lifestyle; incorporating physical activity into lifestyle; using medication safely and for maximum therapeutic effectiveness; monitoring blood glucose and other parameters and interpreting and using the results for self-management decision making; preventing, detecting and treating acute as well as chronic complications; developing personal strategies to address psychosocial issues and concerns; developing personal strategies to promote health and behavioral change; and encouraging the patient to quit smoking.

Medical nutrition therapy (MNT)

Advice is provided by a trained dietitian focusing on energy balance, overweight and obesity -

In overweight and obese insulin-resistant individuals, modest weight loss has been shown to reduce insulin resistance. Thus, weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes.

For weight loss, either low carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to one year)

For a patient on low-carbohydrate diets, there is a need to monitor lipid profiles, renal function and protein intake (in those with nephropathy) and adjust hypoglycemic therapy as needed.

Physical activity and behaviour modification are important components of weight loss programmes and are most helpful in the maintenance of weight loss.

If adults with diabetes choose to use alcohol, daily intake should be limited to a moderate amount (one drink per day or less for adult women and two drinks per day or less for adult men).

Smoking increases morbidity and mortality from micro-vascular complications. Thus, smoking should be totally avoided.

Routine supplementation of vitamins, antioxidants and chromium are not recommended.

Physical activity

People with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50-70 per cent of maximum heart rate).

In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week.

Psychosocial assessment and care

Psychosocial screening and follow-up should include but are not limited to attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional) and psychiatric history.

Major components of diabetes self-management

Survival skills

l Hypo / hyperglycemia
l Sick day management
l Medication
l Monitoring
l Foot care

Daily management issues

l Disease process
l Nutritional management
l Physical activity
l Medications
l Monitoring
l Acute complications
l Risk reduction
l Goal setting/problem solving
l Psychosocial adjustments
l Preconception care/ pregnancy/gestational diabetes management.

The writer is Senior Consultant, Endocrinology, Fortis Hospital, Mohali, and can be contacted at k.singh@fortishealthcare.com