To

The Convener, IEC-NRIAS,

Chinakakani, Guntur,

For information & Not to be typed

TheAapplication
form is to be neatly
Project Title: : TZANCK SMEAR:
USEFUL DIAGNOSTIC
TOOLtyped
IN with Times New Roman, 12
font
size.
The
original
is
to
be
signed
in each page by the investigator
DERMATOLOGY A STUDY
and Venereology
properly numbered
for page
as shown. A soft copy of the proposal in
Department: Dept of Dermatology,
and Leprosy,
NRIGH
word
format
to
be
mailed
to
iecnri@gmail.com
& iec@nrias.net.
(Place of study)
Purpose of the study:- Dissertation
Principal Investigator
Name
: Dr.Chintapalli Sugunavathi
Affiliation
: 2nd Year Post Graduate student
Department of___DVL
NRI MEDICAL College & GH
Email
:suguna.chintapalli@gmail.com
Mobile .No
:
9959704855
Guide
Name
: Dr.G. Venkateswara Rao
Affiliation
: Prof ,Department of DVL
NRI Medical College &General Hospital
Email
:drgvrao55@yahoo.com
Duration of the study :2 years
Sponsors (if any with details) : self
Approval from any other ethics / regulatory committee (if required) : None
I/We shall follow the Good Clinical Practice guidelines and the approved protocol in
conducting the research project. Further I/We declare that any sort of inclusion of text
or Pictorial material which amounts to Plagiarism will be avoided.
Signature of the Investigator (s)

The proposal has been verified as per the requirement mentioned in the information
broacher and forwarded to the IEC, NRIAS for approval. Synopsis of the project,
Informed consent form, Case record form and Study flow chart are enclosed.

Signature of the Guide for dissertation

(With full name and rubber stamp)

(For IEC office use)

Signature of the HOD

(With full name and rubber stamp)

Proposal No.

Date:

SYNOPSIS
TZANCK SMEAR: A USEFUL DIAGNOSTIC TOOL IN DERMATOLOGY A
STUDY
Title: :

Principal Investigator: Dr.Chintapalli Sugunavathi

Department & Institution: Dept.of Dermatology, Venereology and Leprosy, NRIGH
INTRODUCTION

Dermatology, an enclyopaedic subject with more than 1000 named entities, is made
difficult by its morphologically similar type of lesions in different clinical entities. Various
aids which may help making an accurate diagnosis are often of value. These include
cytological studies; skin scrapings for fungal mycelia, examination under woods lamp,
biopsy and immunoflourenscence examinations. Of the various aids mentioned,
cytological studies offers the best source of help particularly in a country like India where
sophisticated equipment for immunological studies is not so freely available. Cytological
studies as a means of diagnosis (cytodiagonsis) in fresh tissues has been introduced by
Dudgeon and Patrick 1 . Later, Dudgeon etal applied the Wet Film examination to tissues
elements from various sites in the body 2. Tzanck first published a report on the use of
cytological studies which may aid in diagnosis of cutaneous lesions 2. Later on various
workers have used cytological studies in cutaneous conditions, and observed that in
Dermatology, cytology is useful in the diagnosis of vesiculo bullous eruptions and
malignant tumors mainly, basal cell epitheliomas. In these conditions the microscopic
appearances are easy to learn and an accurate and rapid diagnosis can be made.
In pemphigus and herpes group of vesiculo bullous disorders cytology can give a
diagnosis when results of the biopsy are ambiguous. It has an advantage that several
lesions may be examined and in conditions like basal cell epithelioma, a confirmation of
diagnosis by cytological studies is justifiable, if biopsy is refused or technically difficult.
Cytodiagnosis has also been recommended by various workers for many skin conditions
including squamous cell carcinoma, Bowens disease, Pagets disease and urticaria
pigmentosa .Therefore cytological studies are useful in the diagnosis of many cutaneous
conditions. However they should not be considered as a substitute for biopsy. In the
present study it is attempted to observe the classical cytological changes, in various
vesiculo bullous disorders and the cytological studies will be correlated to the clinical
diagnosis.The usefulness of this simple bedside procedure to confirm the diagnosis of the
cutaneous conditions would be analyzed in this study

AIM: : This study attempts to illustrate the importance of Tzanck smear and its clinicoVersion : 1.0

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pathological correlation
OBJECTIVES
To study the various cutaneous dermatosis like
a) Immunobullous disorders : Pemphigus Vulgaris, Pemphigus vegetans, P.foliaceus,
P.erythematosus, Bullous Pemphigoid, etc.
b) Drug Reactions

: Toxic Epidermal Necrolysis ,Steven Johnson Syndrome,

c) Cutaneous infections : like Herpes simplex, Varicella, Herpes zoster, Molluscum

contagiosum,

pustular/

bullous

superficial

fungal

infections,

Leishmaniasis

Staphylococcal Scalded Skin syndrome, Bullous impetigo,

d) Geno dermatoses : Hailey Hailey disease, Dariers disease
e) Cutaneous tumors : like Basal cell carcinoma, squamous cell carcinoma, etc.
both with the help of Tzanck smear and histopathologically

REVIEW OF LITERATURE:
Cytological studies as a means of diagnosis (cytodiagnosis) in fresh tissues has been
introduced by Dudgeon and Patrick 1 . Later Dudgeon etal applied the wet film
examination of tissues to elements of Urinary and lymphatic systems, to muscles,
connective tissue, bone, central nervous system, Breast and female genital system 1. They
investigated more than 1000 cases. Dudgeon and Wrigley also demonstrated that particles
of malignant growth can be identified with accuracy in sputum 1. Friedman confirmed the
value of cytology in the diagnosis of malignancy in Oto-Rhino-Laringolical practice 2.

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The cytological studies as a diagnostic procedure has been systematically used at

St.Louis Hospital in Paris (Tzanck, Bourgeis Gavardin and Aron Bruntiere 1948: Tzanck
and Aron Brunetiere, Melki and Aron Brunetiere) 3.
Haber applied this technique in the diagnosis of vesiculo bullous eruptions and
tumors at St. Johns Hospital, London 4. Graham et al reported that accurate diagnosis of
cutaneous premalignant and malignant lesions can be made from both Papanicolaous
smears and frozen tissue sections obtained from specimens 5
Cytological studies are mainly used in Dermatology as a rapid diagnostic method in
vesiculo bullous eruptions and basal cell epitheliomas. In these conditions the
microscopical appearances are easy to learn and accurate and rapid diagnosis can be made.
Same technique has been applied in diagnosis of pemphigus vulgaris limited to the oral
mucosa from other vesiculo bullous conditions affecting oral mucosa by Herman Medak et
al 5. The role of cytology in the diagnosis and differentiation of two major type- allergic
and irritant dermatitis was evaluated by Pavithran 6.. He conducted that cytology will be of
help in differentiating the two types of contact dermatitis by the predominant cells in
cytological smears. Similar study was also conducted by Willes et al

The value of Tzanck smear test in diagnosis of erosive, vesicular, bullous, and pustular skin
lesions was studied by Durdu M, Baba M, Seckin D. at Department of Dermatology,
Bakent University Faculty of Medicine, Adana Hospital, Adana, Turkey (J Am Acad
Dermatol 2008 Dec). Diagnostic reliability of the Tzanck smear in dermatologic diseases
was studied by Erilmaz A, Durdu M, Baba M and published in Int J Dermatol 2014 Feb.

MATERIALS & METHODOLOGY DESCRIBING THE POTENTIAL RISKS AND BENEFITS:

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SOURCE: The patients in this study included both inpatients and outpatients of DVL Dept at
NRI General Hospital, Chinakakani, Guntur.
SAMPLE SIZE/ DURATION : 2 years
INCLUSION CRITERIA
1. Subject of either sex/ any age will be included.
2. Patients willing to give informed consent will be included.

EXCLUSION CRITERIA
1.Subjects not willing for informed consent will be excluded in the study
.
2.Old lesions are not tested as they mask the result
METHODS
After fulfilling of inclusion criteria, consent for participation in the study will be obtained
from the patient.
After obtaining the consent, a detailed proforma will be filled for each patient, covering
various aspects like preliminary information, history of patient lesion, past history,
treatment history, family history and personal history.
This will be followed by detailed physical examination of the patient including
general examination, examination of cutaneous lesions, mucosal, hair, nail, palms, soles,
and other systems. All patients will be subject to the special investigations like Tzanck
smear and histopathology.
The pathologist opinion will be taken apart from basic laboratory investigation for
confirmation of histopathology

STATISTICAL ANALYSIS
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Cytological changes like acantholysis, ballooning degeneration, intranuclear multinucleate

gaint cells, intracytoplasmic inclusion bodies etc will be observed and diagnosis will be
supported by histopathology
.

. Data will be expressed as percentage.

REFERENCES :
1. Whitefield A. A clinical note on Molluscum cartagiosum miliare.
Brit J.Dermet 1929; 41: 10 12.
2. Tzanck A Bull. Soc. Le cytodiagnostic immediate dermatologic;
France Derm. Syph 1947; 7: 68 (Feb).
3. Rook A.J.C and Whimster I.W. The Histological diagnosis of pemphigus.
Brit J Derma1950; 62: 443 446.
4. Wilson, G.T. Cutaneous smears A diagnostic aid in certain malignant lesions
of the skin.J.Invest. Dermat 1954; 22: 173 187
5. Bamforth, J; Osborn, GR. Diagnosis from cells. J Clin Pathol.
1958 Nov; 11(6):473482.
6. Pavithran, K. Cytodiagnosis in contact Dermatitis.
Indian J. Dermatol Venerol lepra1983; Vol. 49, No. 3, P. 99
7. A.R. Solomon, JE Rasmussen, J. Varon. Tzanck smear in the diagnosis of cutaneous
herpes simplex. Clin Paediatr 1994; 33: 698 700.
8. Blank H; Burgoon C.F. Baldrudge.Herpes simplex and varicella zoster virus

Infectious.

Med J Aust 2002 Sep 2; 177 (5), 267 73 Review

9. Blackwell scientific publications.Bullous Eruptions in Text Nook of Dermatology
Vol 2 Ed. Rook et al 4th Edn. P.1646.

10. Lever WF, Lever GS, eds. Non infectious vesicular and bullous diseases: in;
Histopathology of the Skin. 6th edition Philadelphia: J.B. Lippincott Company.
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Page 6 of 15

1983:92-135.
11. Burns T, Stephen B. Histopathology of the skin. General Principles.
7th

Edition Oxford Blackwell; 2004 P 726 7.

12. Cerio R, Calonje E. Histopathology of the skin. General principles. In: Burns T, Stephen
B, Cox N, Griffiths C, editors. Rook's Textbook of dermatology. 7th edn. Oxford: Blackwell;
2004. p. 726-7
13. Atilla ozcan, Mustafagenol, MD, Hulya saglam, MD. Comparison of Tzanck test and
polymerase chain reaction in the diagnosis of cutaneous Herpes simplex and Varicella zoster
infection. Indian Journal of Dermatology, 2007, vol.46 Issue, 11 pages 1177-1179
14. Thomas D. Horn .Journal of the American Academy of Dermatology
December 2008 (Vol. 59, Issue 6, Pages 965-966).

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STUDY FLOW CHART

TITLE : : TZANCK SMEAR: A USEFUL DIAGNOSTIC TOOL IN DERMATOLOGY A

STUDY
PRINCIPAL INVESTIGATOR: DR. CHINTAPALLI SUGUNAVATHI
PLACE OF THE STUDY: DEPT OF DERMATOLOGY, VENEREOLOGY AND LEPROSY, NRIGH

Selection of patients as per the inclusion criteria

Data collection

Statistical analysis

Conclusion

*Recruitment & enrollment of patient or volunteer require advertisement and payment.

Is it true for your study? If not omit these points.
Not to be typed

Can be modified to suit your objective.

*Consider if these points are required for your protocol

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Confidential

INFORMED CONSENT FORM (ICF)

ID No. ______

TITLE : : TZANCK SMEAR: A USEFUL DIAGNOSTIC TOOL IN DERMATOLOGY A

STUDY
PRINCIPAL INVESTIGATOR: DR. CHINTAPALLI SUGUNAVATHI
PLACE OF THE STUDY: DEPT OF DERMATOLOGY, VENEREOLOGY AND LEPROSY, NRIGH
I, -------------(Name)-------------, aged about -------Years, a resident of --------------------------- village of
--------------------------- district, have been detailed about the procedure. I know the benefit and risk of
the said research project. I on my own will, agreed to participate in this study. I understood that my
identity will not be disclosed and I can withdraw from the study at any point of the time without
assigning any reason. My withdrawal from the study will not affect my ongoing treatment.
----------------------------Signature of the witness if necessary

-------------------------------------------Signature of the participant or Gurdian

IN LOCAL LANGUAGE

The meaning of English and Telugu version of consent form must be same.
Not to be typed
The IFC form can be modified to suit your objective.
The IFC form may contain all the information like: Mob. No.; address of
the patient; Bed No.; IP or OP No.; Admission date; Medico legal Case No
and other details of the patient but required for the study; as it is
confidential.

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CASE RECORD FORM (CRF)

ID No. ______

TZANCK SMEAR: A USEFUL DIAGNOSTIC TOOL IN DERMATOLOGY A

STUDY
TITLE :

PRINCIPAL INVESTIGATOR: DR.CHINTAPALLI SUGUNAVATHI

PLACE OF THE STUDY: DEPT OF DERMATOLOGY, VENEREOLOGY AND LEPROSY , NRIGH

Age

Sex

Occupation

Address

Phone No:

Complaints and duration :-

Of: Oozing raw areas/Fluid filled lesions/ solid lesions

Of discharge: Clear fluid/purulent/ Blood

Of: Itching/ Burning sensation/Pain

Of lesions on: Scalp/Face/Limbs/trunk/Intertrigenous areas/Mucoase.

H/o of Present illness:

Onset of disease:

Insidious/sudden/after scratching/after injury.

Commenced as:

Papule/Nodule/Vesicle/Bullae

H/O present or absent

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Itching
Fever and constitutional symptoms
Lesions on the scalp
Oral lesions/difficulty in swallowing
Pain/Burning sensation ass. With oral lesions
Genital lesions
Pain during Micturition/Hematuria
Conjunctival lesions watering/burning sensation, Photophobia
Urticarial lesions/Erythematous lesions/ Eczemas
Hoarseness of voice/dry cough
New lesions occurring around old lesions
Loss of weight/Loss of appetite
Muscle weakness/photosensitivity
Drug intake prior to onset of lesions
Gluten sensitivity
Infections prior to onset of lesions
Seasonal variation/ aggravations/precipitating factors
Past H/O:

H/O

present or absent
Similar lesions in the past
Diabetes/Hypertension/Tuberculosis/Atopy
Renal failure/Porphyrias/Herpes infection

Family H/O:

H/O

present or absentNot to be typed

Must be designed to suit your study.

Similar complaints
Preferably expected to be brief & objective.
No disclosure of Diabetes/HTN/Tuberculosis/Atopy
participants detail which may lead to disclosure of identity.
Instead of address you may think of- Urban/ rural/ Semi-urban
It must be more objective and study related e.g
Family H/o or educational status is vague term. Instead you may consider: Family H/o DM - Present / Absent / Not known
Educational status Illiterate / Literate / Graduate / Professional
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: 1.0
Page 11 of 15
Family
H/O - DM Yes/No/Dont know
BP- ____ / ___ mm of Hg

Treatment H/O:

Untreated/Treated
Treated (regular/irregular), Topical/systemic.

Personal H/O:

Diet
Appetite
Sleep
Bladder and bowels
Habits

General examinations:
Level of consciousness/built/nourishment
Signs of

Pallor

: Present/Absent

Icterus

: Present/Absent

Cyanosis

: Present/Absent

Clubbing

: Present/Absent

Koilonychia

: Present/Absent

Lymphadenopathy :

Pedal edema

Vital Data
Pulse rate

Blood pressure

RR

Cutaneous Examination:
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Morphology of lesion :papule/nodule/ vesicle/bullae

Distribution and Areas of Involvement
Localised/Generalised

Symmetrical/Asymmetrical

Scalp/ face/ Flexour aspects/Extensor aspects/palms and soles/

Trunk/Abdoment/Intertriginous area/Mucosae.
Configuration : Discrete/Linear/Annular/Herpitiform/Serpiginous/Corymbose
Perilesional skin colour

Consistency of Lesions

: Flaccid/Tense/Soft/Indurated/Friable/Infiltrated

Contents of Lesions

: Clear fluid/Pus/Blood/Cornified material

Scarring/Milia formation:
Signs:
Bulla spread sign:
Nikolskys sign
Koebnerization

:
:

Mucosae:
Oral
Conjunctival
Genital
Rectal
Scalp
Hair

Diffuse hair loss

Patchy

Cicatricial / Noncicatricial
Nails

Onycholysis
Nail dystrophy

Other systems
Cardiovascular system:
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Respiratory System

Liver

Spleen

CNS

Provisional Clinical Diagnosis:

Routine Investigations : Hb%,TC,DC,ESR,Renal function tests,LFT,Complete urine
examination ,Chest Xray,etc.

Specific Investigations:
Tzanck smear:
Skin biopsy for Histopathology:

Final Diagnosis:

Signature of the person collecting the data

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