Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : January | Volume : 16 | Issue : 1 | Page : ZC18 - ZC21 Full Version

Dexamethasone Induced Perineal Pruritus in Patients Undergoing Minor Oral Surgical Procedures- A Prospective Cohort Study


Published: January 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/50894.15854
Sukhvinder Bindra, Vinitha Annavarjula, David Tyro

1. Senior Consultant, Department of Dentistry, Apollo Hospitals, Secunderabad, Telangana, India. 2. Fellow in Oral Oncology, Department of Oral Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India. 3. Private Practioner, Dental Square Dental Clinic, Secunderabad, Telangana, India.

Correspondence Address :
Dr. Sukhvinder Bindra,
House No. 20, Radha Regal Rows, Near Kalyan Gardens,
Yapral, Secunderabad, Telangana, India.
E-mail: drsukhvinderbindra@gmail.com

Abstract

Introduction: Dexamethasone is frequently used by oral and maxillofacial surgeons to control postoperative oedema and pain in minor oral surgery procedures. Intravenous administration of dexamethasone may result in perineal pruritus i.e., perineal itching, pain and burning sensation. Different studies previously have reported these symptoms in patients. The incidence of these symptoms can vary between 25-100% depending on the dose of dexamethasone administered.

Aim: To evaluate the relationship between intravenous administration of dexamethasone and perineal pruritus in patients requiring minor oral surgical procedures; and its association with the phase of the menstrual cycle in female patients.

Materials and Methods: A prospective cohort study was conducted in the Department of Dentistry, Apollo Hospitals, Secunderabad, Telangana, India, which included 81 patients (43 females and 38 males) between October 2020 to March 2021. All patients included in the study were given preoperative 2 mL (8 mg) of intravenous dexamethasone, 30 minutes before commencing the minor oral surgical procedures and patients were enquired about symptoms of perineal pruritus. Female patients were asked about the phase of the menstrual cycle. All observations recorded were analysed using the Chi-square test and Spearman’s analysis. Statistical Package for the Social Sciences (SPSS) version 26.0 software was used for statistical analysis and p-value <0.05 was considered statistically significant.

Results: A total of 81 patients (aged 19-52 years) were assessed, with the mean age of male patients being 29.3 years, and the mean age of female patients being 28.7 years. Most patients (female 82% and male 35%) experienced symptoms of itching and burning sensation for 60-90 seconds, which subsided without any further treatment. Female patients out numbered the male patients in experiencing the symptoms of perineal pruritus significantly (p-value <0.001). Correlation coefficient was 0.234 (p-value=0.037) which showed a weakly but positive correlation which was statistically significant between the phase of the menstrual cycle and symptoms experienced.

Conclusion: The study established a relation between the administration of i.v. dexamethasone and perineal pruritus. The symptoms were found to be more evident in females and the intensity of the symptoms varied with phases of the menstrual cycle. Females in the postovulatory phase and postmenopausal phase had experienced it more than others. Hence, the knowledge of such incidence and prior education of the patient would reduce the unpleasant experience.

Keywords

Anti-inflammatory agents, Endometrial cycle, Glucocorticoids, Ovarian cycle, Perineum

Dexamethasone is a synthetic glucocorticosteroid with minimal mineralocorticoid activity, which has been in use since the 1960’s to reduce inflammation in a range of conditions, including allergic reactions, autoimmune disorders, inflammatory disorders and certain types of cancers. In 1977, the World Health Organisation (WHO) listed it in the model list of essential medicines, as part of multiple formulations and thereafter to date it has been an off-patent product, which is also economically viable in most of the countries (1).

Dexamethasone has also been preferred and proposed by Oral and Maxillofacial Surgeons to control postoperative oedema and pain because of its formidable anti-inflammatory and analgesic properties (2). It is commonly given perioperatively, either intramuscularly or intravenously. Intravenous administration of dexamethasone in third molar surgery has been extensively studied (3),(4),(5),(6),(7) and it has emerged that it bears no detrimental impact on wound healing, even with patients who are predicted to be at high risk for delayed clinical recovery (7).

It is frequently used as a single dose treatment to prevent postoperative swelling, pain, nausea and vomiting and when administered, did not have any significant long or short term adverse effects (8). It is also worth mentioning that intravenous administration of dexamethasone may result in perineal pruritus i.e. perineal itching, pain and burning sensation. These symptoms have been reported by many patients in different studies (9),(10),(11),(12),(14).

Perineal pruritus incidence has been found to vary (25-100%), in studies conducted by different authors, depending on the dose of dexamethasone used (9),(10),(15),(16),(17),(18),(19). Perineal Pruritus after intravenous dexamethasone is not uncommon (9),(10),(15),(16),(17),(18),(19) but has not been studied in the oral and maxillofacial speciality.

The current study was conducted to analyse and evaluate the association between intravenous administration of dexamethasone and perineal pruritus, in patients requiring minor oral surgical procedures, and to determine its correlation with menstrual cycle phase (preovulation, ovulation, postovulation and postmenopausal) in female patients.

Material and Methods

A prospective cohort study was conducted in the Department of Dentistry, Apollo Hospitals, Secunderabad, Telangana, India, from October 2020 to March 2021. Requisite, prior Ethical Clearance with number (AHS-ADS-001/10-20) was obtained to conduct the study and informed consent was taken from the patients for administering the drug. Total 81 patients (43 females and 38 males) were selected randomly irrespective of their caste, creed, religion or socio-economic status.

Sample size calculation: The sample size was calculated using G Power software (version 3.1.9.4). Based on the previous studies (20),(21) the calculated effect size of 0.35 and keeping the standard values of alpha error at 0.05 and power of the study at 95%. Fixing the confidence interval at 95% with 5% level of precision the minimum sample size of the study was 79.

Inclusion criteria: Patients with American Society of Anaesthesiology (ASA) I classification (22) and no history of steroid or analgesics intake were included in the study.

Exclusion criteria: Patients of ASA II,III,IV and with history of steroid or analgesics intake were excluded from the study.

Study Procedure

Local anaesthesia administered was 2% lignocaine with 1:80,000 adrenaline used as nerve block and infiltration. All patients considered in the study were given preoperative 2 mL (8 mg) of intravenous dexamethasone, 30 minutes (23) before commencing the minor oral surgical procedures like extraction of difficult and impacted teeth, apicoectomy. The advantage of administering the medicine prior to surgery ensures better drug absorption and the therapeutic blood level shall be achieved well before the inflammation begins (24).

Injection dexamethasone (brand name injection dexasone) manufactured by Cadila Pharmaceuticals containing 4 mg of dexamethasone phosphate in 1 mL of the solution with preservative sodium methylparaben (5% w/v) and sodium propylparaben (0.02% w/v) was used. All patients received an undiluted intravenous dose of 2 mL (8 mg) preoperatively. They were injected intravenously in an antecubital vein using a 25 gauge needle attached to 2 mL Leur-lock syringes (unolok 2 mL syringes by Hindustan Syringes and Medical Device).

Patients were elucidated about the side-effects of perineal pruritus and were asked to report any itching or burning sensation and pain in the perineal area during and post the injection. A 7-point Likert scale was used for assessment and grading of pain. Female patients were specifically enquired, about their menstrual cycle, duration of their being in their preovulation, present and postovulation phase to establish any relation of their symptoms with the phase of their menstrual cycle.

Statistical Analysis

Observations were recorded and were analysed by a statistician using Statistical Package for the Social Sciences (SPSS) version 20.0 software. A Chi-square test was used to show the gender-wise distribution of study subjects for perineal pruritus. Spearman’s correlation was analysed between the stages of the menstrual cycle and perineal pruritus among female patients in the study. The p-value <0.05 was considered statistically significant.

Results

The present study was conducted on 81 patients who had undergone minor surgical procedures under local anaesthesia as depicted in (Table/Fig 1). The age of the patients ranged from 19-52 years. The mean age of male patients was 29.3±8.05 years and that of female patients was 28.7±6.25 years.

Most patients experienced symptoms of itching and burning sensation in the perineum (n=48) 60% for 60-90 seconds which subsided, without any further treatment. One patient could not define the feeling experienced and was not included for the analysis part of the study. The pain was felt by only three patients which subsided after a while and was scored 4 (moderate) on Likert scale. In the present study, most female subjects showed the presence of perineal pruritus (82%, n=32) as compared to the males (35%, n=13). This difference was seen to be statistically highly significant p-value <0.001 (Table/Fig 2).

A 25.58% of female patients were in preovulation phase of their menstrual cycle. A 27.9% of the females were in the postovulatory phase. A 34.88% of them were in postmenopause phase (Table/Fig 3).

There was a statistically significant but weakly positive Spearman’s correlation between the phase of the menstrual cycle and perineal pruritus symptoms experienced (r=0.234, p-value=0.037).

Discussion

Inflammation and oedema are limited by the preoperative administration of corticosteroids. This is in agreement with a study conducted by Bamgbose BO et al., and Antunes AA et al., who concluded that dexamethasone is the preventive strategy for limiting postoperative oedema and trismus following third molar extractions (25),(26). Moore PA et al., also reiterated the efficacy of pre-emptive NSAIDs and corticosteroids in avoiding a variety of postoperative complications (27). Postoperative swelling and oedema may be partly due to the conversion of phospholipids to arachidonic acid by phospholipase A2, and the resultant production of leukotrienes, prostacyclins, prostaglandins and thromboxane A2 which act as mediators of the inflammatory response. The use of steroids may act to inhibit the initial step in this process (23).

They act by inhibiting vascular dilation produced by histamine and reducing the transudation of fluids, thus the formation of oedema. They hinder deposition of fibrin around the inflamed area and inhibit leukocyte chemotaxis, phagocytosis, Kinin generation and arachidonic acid formation, thereby suppressing the surge for the formation of prostaglandins and cyclooxygenase end products. All phases of inflammation are blocked which accounts for the anti-inflammatory potency of steroids resulting in a significant reduction in oedema and swelling (28).

Corticosteroids have been used effectively as an adjunct to analgesics in oral and maxillofacial surgery to reduce postoperative oedema and pain (24). Corticosteroids that can be used in oral surgical procedures include long-acting drugs like dexamethasone, betamethasone, intermediate duration like prednisone, prednisolone, methylprednisolone, and triamcinolone, short-acting drugs hydrocortisone (29).

Dexamethasone is universally preferred among these for minor oral surgical procedures. It is one of the most active glucocorticoids, being about 25-30 times as potent as hydrocortisone. Absorption of dexamethasone is rapid following intravenous injection. The biological half-life of dexamethasone is about 190 minutes and small amounts of dexamethasone are bound to plasma protein. It is metabolised primarily in the liver and inactive metabolites are excreted in the urine, mainly as glucuronides and sulphates, and also as unconjugated metabolites. Small amounts of unchanged drugs are also excreted in the urine. Up to 10-65% of a dose of dexamethasone is excreted in the urine within 24 hours (30).

The potential advantage of dexamethasone is that of its low cost and long clinical effect, lasting 24-36 hours (31). To achieve the desired anti-inflammatory effects, corticosteroids must be administered in doses exceeding the normal physiologic amounts released by the body (32) and should preferably be given before the infliction of tissue damage and not during or after surgery to achieve better control on postoperative pain (33),(34) in addition to less nausea and vomiting.

A preoperative dose of 8 mg given intravenously has been recommended by many authors (33),(34),(35) and our study also has followed the same protocol. Al-Shamiri HM et al., in their study found that preoperative oral administration of 8 mg dexamethasone was more effective in reducing oedema following third molar surgery compared to postoperative administration of the same dose (4).

Intravenous route i.v. route administration was preferred as preoperative intravenous dexamethasone facilitates recovery reducing pain and postoperative nausea and vomiting (36). Intravenous dexamethasone does not seem to cause any significant long or short-term adverse effects, but the unfavourable effect of transient excruciating perineal itch and pain has been documented previously(17). In the present study, patients experienced burning sensation and itching in the perineal region for a short period (60-90 seconds) which subsided without any intervention. This is in agreement with a study conducted by Perron G et al., who observed short-lived perineal itching and burning sensation postadministration of i.v. dexamethasone (13).

Neff SP et al., have stated that pain appears to be short-lived and pain may be reduced by either dilution and slow drugadministration (e.g., 8 mg dexamethasone diluted in 50 mL of 0.9% sodium chloride, infused over 1 minute) (10),(27),(28). Analogous conclusions were witnessed by Singh M et al., where they stated that 43% of patients were having perineal pruritus after receiving 0.15 mg/kg dexamethasone via a peripheral line (9). They concluded that dexamethasone used for prophylaxis and treatment of postoperative nausea pain vomiting may cause perineal pruritus/pain of variable intensity in awake patients.

There is no established hypothesis to explain these adverse effects, but it is speculated that corticosteroid phosphate esters such as the dexamethasone sodium phosphate, as used in the present study cases, are the cause of the perineal pain and irritation. Perineal irritation has been described with hydrocortisone-21 phosphate sodium and prednisolone phosphate. Incidence and severity of burning sensation and itching are directly proportional to the concentration of organic phosphate in the blood (10),(16).

Itch pathway and itch sensation are received by the unspecialised free nerve endings located close to the dermo-epidermal junction and is transmitted by polymodal, unmyelinated C fibres entering the spinal cord and thalamus. The important pharmacological mediators of itch sensation include histamine, acetylcholine, substance P, Calcitonin Gene-Related Peptide (CGRP), opioid peptides, proteases, bradykinin, serotonin, platelet-activating factor, neurotrophins, prostaglandin E and cytokines (37).

Wang J et al., have proposed that dexamethasone may participate in the pathogenesis of pruritus through activated sodium channels in peripheral unmyelinated C fibre polymodal afferents within superficial layers of skin and mucous membrane (14).

The short duration of pain and pruritus (60-90 seconds) observed in our study might be attributed to the time required for the compound to be hydrolysed to phosphate ions and dexamethasone (38). Repeated administrations could cause similar effects, suggesting this as a potential aetiology. However, the path physiology of this rare side effect remains a conundrum and further research is required.

Singh M et al., observed that incidence of perineal pruritus was more in female patients and it was statistically significant (p-value <0.05) (9). Rewari V et al., conducted a prospective, randomised, double blind placebo controlled study on use of fentanyl pretreatment for alleviation of perineal symptoms following preoperative administration of intravenous dexamethasone sodium phosphate and had similar observations (39). In the present study, both female and male patients were observed to report the symptoms, but females outnumbered male patients.

In a study by Perron G et al., among the twenty patients included in the study all the ten females (100%) experienced the symptoms while only three males were affected and Gu CY et al., observed that females had a higher incidence of dexamethasone-induced perineal pruritus (p-value <0.05) (13),(40). Their results are also similar to the present study where the incidence of perineal pruritus was more in female patients (p-value <0.001). They had also concluded in their study that females had a higher incidence of dexamethasone-induced perineal pruritus.

Authors of the present study further tried to find out the correlation between the appearances of pruritus and the menstrual phase in female patients and observed a weakly positive yet significant relationship. (Spearman’s coefficient value=0.234 with p-value=0.037). It has been noted that females in the postovulatory phase and postmenopausal phase were affected more with these symptoms. Similar findings have been mentioned by Swamiappan M in their study (37). This could be attributed to decreased oestrogen levels after ovulation and menopause as a cause for vaginal dryness (41). Other authors speculated that the threshold levels of released neurotransmitters were lower in females (40). The current study did not test the level of neurotransmitters.

It has been recommended that i.v. dexamethasone should be diluted in 50 mL saline and must be administered over 5-10 minutes to reduce the intensity of symptoms (13). It has been proposed that dilution and prolonged injection time might have resulted in a slower release of neurotransmitters and not reaching the threshold levels, which ultimately helped to reduce the symptoms (40).

Limitation(s)

A larger sample size should be included to establish more accurate, substantial and statistical analysis of result on the correlation of the symptoms of perineal itching and pain with the menstrual cycle. Changes in the menstrual flow were not included in this study.

Conclusion

Dexamethasone induced perineal irritation is a distinctive phenomenon that could be appalling to patients without them being cognizant of the real reason behind it. The study concludes that females are more prone to it vis-a-vis male. It transpires that females in postovulatory and postmenopausal phase experienced symptoms of perineal pruritus more than the other phases of menstrual cycle. However, this aspect needs further deliberation with research work done with a larger spectrum of patients. It is important to be acquainted with these symptoms and necessary precaution to be taken for preventing or minimising the suffering of patients.

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DOI and Others

DOI: 10.7860/JCDR/2022/50894.15854

Date of Submission: Jun 25, 2021
Date of Peer Review: Aug 17, 2021
Date of Acceptance: Nov 13, 2021
Date of Publishing: Jan 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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