https://www.nepjol.info/index.php/NJDVL/issue/feed Nepal Journal of Dermatology, Venereology & Leprology 2022-09-30T09:32:38+00:00 Dr Deeptara Pathak Thapa njdvl.sodvelon@gmail.com Open Journal Systems <p>The Nepal Journal of Dermatology, Venereology &amp; Leprology (NJDVL) serves as the official journal of the Society of Dermatologists, Venereologists &amp; Leprologists of Nepal (SODVELON), disseminating and sharing scientific dermatological information among doctors across the country.</p> https://www.nepjol.info/index.php/NJDVL/article/view/47326 Chronic Bullous Disease of Childhood: A Case Report and Review of Literature of Bullous Diseases in Children 2022-08-08T11:44:27+00:00 Susmita Pradhan sush_pradhan@hotmail.com Krishna Jha kjha5962@gmail.com Priyanka Kumari preee123@gmail.com Shristi Shrestha sonyjony@gmail.com Anil Kumar Jha dranilkjha@hotmail.com <p>We describe a case of a 5-year-old boy who presented with multiple mild itchy and painful blisters predominantly over his trunk and limbs for one year with multiple tense bullae with hypopyon signs resulting in a half-and-half appearance of the blisters. A skin biopsy showed subepidermal separation with predominantly neutrophils and eosinophils in the bulla cavity and mixed infiltrate in the papillary dermis. We would like to report a case of chronic bullous disease of childhood and review its differentials for diagnostic approaches to blistering disease in children.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/44415 Better Disease Control by Multidrug Regimen in Scabies: A Randomized Controlled Trial 2022-04-29T06:00:51+00:00 Prajwal Pandey prajwal.p@gmail.com Sudha Agrawal sudha92@yahoo.com <p><strong>Introduction: </strong>Scabies is a highly resilient condition with varying morbidity worldwide. The treatment options widely used for the disease include topical permethrin 5% and oral Ivermectin with similar efficacy. Treatment failure due to non-compliance is a major problem with the current treatment modalities.</p> <p><strong>Objectives</strong>: This study was designed to compare the efficacy of combination to the gold standard treatment regimen of scabies.</p> <p><strong>Materials and Methods: </strong>A randomized controlled trial was done with 212 patients, divided randomly into two groups Group 1 and Group 2. Group 1 were treated with two-time application of 5% permethrin one week apart while Group 2 were treated with a combination of 5% permethrin and oral ivermectin (200μg/kg) on a single day. Patients were followed up every week for 4 weeks to assess the efficacy and adverse events.</p> <p><strong>Results: </strong>The treatment efficacy in group 2 was more compared to group 1 after 2 weeks of follow up (72.6% vs 65.1% after 1 week; 89.6% vs 80.2% after 2 week) however it was not statistically significant. After 4 weeks of follow up, the treatment efficacy in both the groups was similar. The reduction in intensity of itching was almost similar in both the groups at every follow up.</p> <p><strong>Conclusion: </strong>The combination of 5% topical permethrin and oral ivermectin showed earlier resolution of clinical symptoms compared to 5% topical permethrin alone repeated in 1 week. The reduction in intensity of itch was similar in both the groups.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/45068 Quality of life in Patients with Melasma: A Hospital-Based Study 2022-05-15T05:49:46+00:00 Priyanka Mainali mainalip92@gmail.com Anil Kumar Jha dranilkjha@hotmail.com Shristi Shrestha drshristi@nmcth.edu Deeptara Pathak Thapa drdeeptarapathak@yahoo.com Smita Joshi smitaz@gmail.com Bibush Amatya bibush.amatya@gmail.com <p><strong>Introduction: </strong>Melasma is the most common cause of facial melanosis and one of the most common diseases presenting to the Dermatology department. It can lead to psychological and emotional distress for the patients and can hamper their quality of life. So, this study was done to assess the quality of life among patients with melasma so that the need for couseling of these patients could be assessed along with medical treatment.</p> <p><strong>Materials and Methods: </strong>This was a hospital based cross sectional study with 205 clinically diagnosed cases of melasma during the study period of one year. Melasma area severity index (MASI) score was recorded for each patient. Melasma quality of life was evaluated using the Melasma related Quality of Life (MELASQOL) score. MASI score and MELASQOL score were correlated using the Chi square test and socio-demographic details were also recorded.</p> <p><strong>Results: </strong>The mean MASI score in our study was 14.39 and the mean MELASQOL score was 34.98. The correlation of the MASI score with the MELASQOL score was found to be statistically significant (p value = 0.000).</p> <p><strong>Conclusion: </strong>MELASQOL score can be used to assess the quality of life in patients with melasma and the impairment in quality of life depends upon the MASI score.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/45390 Trichoscopic Study on Tinea Capitis: A Hospital Based Study 2022-05-30T06:38:40+00:00 Anisha Joshi janishia27@yahoo.com Anil Kumar Jha dranilkjha@hotmail.com Shristi Shrestha sonyjony@gmail.com Deeptara Pathak Thapa drdeeptarapathak@yahoo.com Smita Joshi smitaz@gmail.com Bibush Amatya doc_bibush@hotmail.com <p><strong>Introduction: </strong>Tinea capitis is a common dermatophyte infection of the scalp and hair shaft, most commonly observed in children. Trichoscopy is nonivasive tool which helps in early diagnosis and prompt treatment of tinea capitis.</p> <p><strong>Objectives: </strong>This study was carried out with the aim to describe the trichoscopic features of tinea capitis and to find out its different clinical variants with the aid of trichoscopy.</p> <p><strong>Materials and Methods: </strong>This is a hospital based cross sectional descriptive study conducted from 1<sup>st</sup> January 2019 to 31<sup>st</sup> December 2019. All patients clinically diagnosed with tinea capitis were included in the study.</p> <p><strong>Result: </strong>A total of 50 patients with tinea capitis were recruited. The most common age group was found to be 6-10 years (52%) and 27 patients (54%) were female. Majority of the population were students, i.e. 46 patients (92 %). Family history was positive in 38% of cases.</p> <p>The clinical variants seen were black dots in 20 patients (40%), followed by gray patch in 15 patients (30%), kerion in 8 patients (16%) and combined type (both gray patch and black dots) in 4 patients (8%). The most common trichoscopic feature were black dots in 40 (80%), followed by comma hairs in 38 (76%), corkscrew hairs in 33 (66%), and broken hairs in 24 (48%).</p> <p><strong>Conclusion: </strong>This study highlighted that the use of trichoscopy as non-invasive tool helped in diagnosing the cases of tinea capitis without the use of wood’s lamp and laboratory investigations.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/45090 Quality of Life in Nepalese Patients with Non-Scarring Alopecia: A Cross-Sectional Observational Study at a Tertiary Center 2022-05-15T04:24:34+00:00 Sushil Paudel paudelsushil@gmail.com Prajwal Pudasaini prajwalpudasaini@gmail.com Niraj Parajuli drnirajparajuli@gmail.com <p><strong>Introduction</strong>: Alopecia is a dermatological condition characterized by the loss or reduction of hair. Alopecia areata and androgenetic alopecia are fairly common hair disorders. Hair loss causes a significant impact in person’s life which may lead to loss of self-confidence and distorted body image.</p> <p><strong>Materials and Methods</strong>: All consenting patients with alopecia areata and androgenetic alopecia, presenting to the out-patient department from September 2020 to August 2021 were enrolled based on convenience sampling method in this observational study. Ethical clearance was obtained from the ethical review committee of same institute (IRC protocol no.9/2021). All patients completed the Nepali Dermatology Life Quality Index questionnaire. Statistical Package for Social Studies version 25 was used for statistical analysis. Mean scores between groups were compared with Mann-Whitney U test. </p> <p><strong>Results</strong>: Out of 142 patients, there were 79 (55.6%) males and 63 (44.4%) females. There were 48 (33.8%) patients of alopecia areata while ninety-four (66.2%) had androgenetic alopecia. The mean total of Dermatology Life Quality Index score was 8.16 (±6.126). Mean score of females was 9.16±5.858 which was significantly higher than that of males 7.37±6.258 (p&lt;0.05) and the score of the androgenetic patients (9.45±6.094) was significantly higher than that of areata patients (5.65±5.417) (p&lt;0.001). All sub-domains of the questionnaire were impaired more in female. Increasing duration of the disease and hair loss in any first degree relative increased the impairment in quality of life significantly.</p> <p><strong>Conclusion</strong>: The quality of life in females were more affected as compared to males in both kinds of hair loss. However, patients with androgenetic alopecia had a greater impairment than patients with alopecia areata in our population.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/45881 Dermoscopy of Psoriasis: A Cross Sectional Study 2022-06-17T05:32:19+00:00 Deeptara Pathak Thapa drdeeptarapathak@yahoo.com Harihar Adhikari harihar549@gmail.com Sajana Bhandari sajanajasana@gmail.com <p><strong>Introduction: </strong>Dermoscopy is a non-invasive tool that aids in the diagnosis of dermatological diseases.</p> <p><strong>Objectives: </strong>The study aims to evaluate the dermoscopic features of psoriasis in the skin.</p> <p><strong>Materials and Methods: </strong>All patients clinically diagnosed with psoriasis were enrolled in the study. Dermoscopic findings were studied using a handheld pocket dermoscope (Dermlite DL1) with high magnification. Dermoscopic examination used both polarizing and non-polarizing lenses.</p> <p><strong>Results</strong>: The age of the patients ranged from 12 years to 58 years, and the mean age of presentation was 30 years (+/-12.7 years). There were 52% females and 48% males. In dermoscopy, vascular changes were seen in 90%. Vessel arrangement was seen as uniform in 80% of the cases and non-uniform in 20%. Dotted vessels were seen in 88%, glomerular and comma-shaped vessels in 2%. In 94%, white scales were seen, followed by yellow scales in 2% and mixed types in 4%. The background color was red in 68% of cases, pink in 26%, and brownish in 6%. Pigmentary changes were observed in 16%. Follicular changes were observed in 6%. </p> <p><strong>Conclusion</strong><strong>: </strong>The present study analyzed the characteristic of dermoscopic features in psoriasis. Further studies should be conducted, including inflammatory disorders and their correlation with dermoscopic features.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/45971 Pattern of Dermatological Diseases During the Lockdown and Pre-COVID Period at a Tertiary Care Center in Nepal 2022-06-20T09:21:31+00:00 Madhu Gyawalee drmadhupau@gmail.com Monique Kafle moniquekafle@pahs.edu.np Amit Amatya amitamatya@pahs.edu.np Bhaskar Mohan Kayastha bhaskarkayastha@pahs.edu.np <div> <p><strong>Introduction</strong>: Coronavirus disease 19 (COVID-19), which started in China, affected many countries in a short time and spread globally. The Nepal government implemented a strict lockdown to stop the spread of this viral infection.</p> </div> <div> <p><strong>Objectives</strong>: Analyzing the impact of COVID-19-induced lockdowns in the pattern of dermatological diseases in comparison to the non-COVID period of 2019.</p> </div> <div> <p><strong>Materials and methods</strong>: A retrospective cross-sectional study was done by reviewing the data from dermatology out-patients records for four months of each lockdown and four months of the non-COVID period.</p> </div> <div> <p><strong>Results</strong>: There was a 49% and 7% reduction in visits of dermatology outpatients during the first and second lockdown, respectively compared to the pre-COVID period. The number of non-infectious diseases was more compared to infectious diseases. Bacterial infection decreased by 1%. Herpes zoster and scabies increased by 0.5-1% during lockdowns. Cases of eczema and urticaria increased by 2% and 3-5.5% during the first and second lockdowns, respectively. Papular urticaria and sexually transmitted infections decreased by 1% during the second lockdown. Consultations for melasma increased by 1.5%.</p> </div> <div> <p><strong>Conclusion</strong>: There was a reduction in patient visits during both lockdowns. However, a marked reduction was seen during the first lockdown compared to the pre-COVID period.</p> </div> <div> <p>Pruritic conditions like eczemas, urticarias, and scabies increased, whereas papular urticaria decreased. Pigmentary disorders decreased, but visits for melasma increased. All bacterial infections decreased, whereas herpes zoster increased among viral infections. Chronic diseases like psoriasis and acne vulgaris decreased slightly. The number of sexually transmitted infections (STIs) also decreased. There was no difference in the proportion of infectious and non-infectious diseases compared to the pre-COVID and the lockdown periods.</p> </div> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/46816 Perception of Tele-dermatology Consultation among Social Media Users 2022-07-19T14:00:18+00:00 Sishir Poudel sishir.poudel.sh@gmail.com Sushan Pokharel sushanpokharel@gmail.com Sudha Agrawal sudha92@yahoo.com Suchana Marahatta suchanamarahatta@yahoo.com <p><strong>Introduction:</strong> Tele-dermatology is significant for faster delivery of health care particularly in geographically isolated areas.</p> <p><strong>Objectives</strong>: To know the perceptions of tele-dermatology consultation among social media users in terms of impact, their willingness to pay for the consultation and the barrier they may have during the consultation.</p> <p><strong>Materials and Methods</strong>: An exploratory cross-sectional study was done on 360 social media users online regarding impact (time and cost), willingness to pay and the barriers of tele-dermatology consultation by using the questionnaire.</p> <p><strong>Results</strong>: Participants believed the services to be time saving (91.7%) and cost effective (89.2%). Majority (70.3%) were willing to pay for services and 30.8% agreed NRs.400 fee and 37.2% agreed NRs.200 fee. Those willing to pay less than NRs 200 felt “services not being 100% reliable (59.3%), OPD price being cheaper (48.1%), saving doctor’s time too (38.3%), Wi-Fi and mobile data also cost (22.2%) and transportation fee could not be accounted to the doctor’s fee (13.6%)”. While participants not willing to pay any money responded as the services not being 100% reliable (60.7%) and preferred to visit OPD for consultation (47.7%) if paying the price. The barrier in using tele-dermatology were dissimilarity from face-to-face interaction, poor networking in rural area, unavailability of physical examination, low camera quality leading to misdiagnosis and not convenient for multiple lesions.</p> <p><strong>Conclusion: </strong>The impact of tele-dermatology in terms of cost and time is appreciable. However, for better service implementation the barriers of the participants, needs to be evaluated</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/47617 Dermoscopy of Non-Melanocytic Skin Tumors: A Descriptive Study in a Tertiary Care Hospital 2022-08-18T08:48:21+00:00 Deeptara Pathak Thapa drdeeptarapathak@yahoo.com Sajana Bhandari sajanajasana@gmail.com Harihar Adhikari harihar549@gmail.com Sammi Joshi Joshisammi678@gmail.com <div> <p class="root-block-nodeCxSpFirst"><strong>Introduction: </strong>Dermoscopy is a non-invasive technique that enhances visualization of morphological lesions invisible to naked eye examination and aids in clinical diagnosis. We study its role in non-melanocytic skin tumors.</p> <p><strong>Objectives:</strong> The purpose of this study was to evaluate and compare the dermoscopic features of non-melanocyte skin tumors of skin</p> </div> <div> <p class="root-block-nodeCxSpMiddle"><strong>Materials and Methods</strong>: A cross-sectional hospital-based study including patients clinically diagnosed as non-melanocytic epidermal tumors was conducted. All dermoscopic findings were studied using a handheld pocket dermoscope (Dermlite DL1) and recorded in a preset proforma.</p> </div> <div> <p class="root-block-nodeCxSpLast"><strong>Results:</strong> A total of 100 patients were enrolled in the study with mean age of 37 (+/-18.34). There were 56 % females. The face was the commonest site of involvement (56%). Seborrheic keratosis was the commonest clinical diagnosis (55%), followed by pyogenic granuloma 8%, cherry angioma 7%, haemangioma 6%, basal cell carcinoma 5%, achrochordons 4%, xanthelasma, and sebaceous hyperplasia in 3% each. Squamous cell carcinoma and actinic keratosis were seen in 2% each; Angiokeratoma, Bowens disease, stetocytoma multiplex, syringoma, and neurofibroma were all found in 1% of the patients. In dermoscopy, vascular changes were seen in 41% patients, which appeared as regular in 56.1% and rest 43.9% as irregular. Non-vascular changes were seen in 68%. Dermoscopic findings of vascular and non-vascular changes were statistically significantly associated with various types of non-melanocytic epidermal tumors (P &lt;0.05).</p> </div> <div> <p class="BodyACxSpFirst"><span class="None"><strong>Conclusion: </strong></span><span class="None">Our study shows histopathological correlation with the existing dermoscopic characteristics increases the diagnostic accuracy of various non-melanocytic tumors. However, more studies are warranted to statistically prove its utility.</span></p> </div> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/47631 Cutaneous Manifestations In the Patients With Covid 19: A Prospective Clinical Analysis 2022-08-19T09:03:21+00:00 Sagar Mani Jha sagarmanijha@gmail.com Nabin Bhakta Shakya docnabin@yahoo.com Anil Kumar Singh Dangol anildangol2010@gmail.com Sunil Shakya sunil3964@gmail.com Jyotshna Yadav jyotshnayadav123@gmail.com Manisha Maharjan manisha.mhrjn@gmail.com Shrikant Panday shrikantpanday39@gmail.com <p><strong>Introduction</strong>: The COVID-19 pandemic has become a major health care issue worldwide. The surge in cases was seen in the second wave, with more people getting hospital admissions. An accurate and rapid identification of cutaneous manifestations is vital to early diagnosis and better prognosis. The aim of the study was to determine cutaneous manifestations in patients with COVID-19.</p> <p><strong>Materials and Methods</strong>: This prospective observational cross-sectional hospital-based study was conducted from June 2021 to September 2021. Patients admitted to the hospital were examined by the dermatologists. All inpatients diagnosed with COVID-19 with RT PCR were included. Types, patterns and how the skin lesions changed its course during illness were recorded. Ethical clearance was taken from IRC. Statistical analysis was done with SPSS Version 20.0.</p> <p><strong>Results</strong>: A total of 452 COVID-19 RT-PCR-positive patients were enrolled out of which 97(21.5%) had skin lesions. Out of 131 comorbid patients, 40(30.5%) had skin lesions. Urticarial wheals and erythema nodosum were seen in 21(4.6%) each and were the most common manifestation, followed by exanthema in 17(3.8%).</p> <p><strong>Conclusion</strong>: Study showed maximum patients with COVID-19 had urticaria and erythema nodosum. It is important to know the types of skin lesions for early diagnosis. In order to prevent the spread patient can be sent for investigations on time. More elaborate studies with multicenter involvement are recommended.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/45638 Non-FDA-Approved Uses of Apremilast in Dermatology: A Review of Current Available literature 2022-07-11T03:55:58+00:00 Saurabh Bhatia sabh_kai@hotmail.com <p><strong>Introduction: </strong>Apremilast, an oral phosphodiesterase-4 inhibitor, decreases the production of pro-inflammatory cytokines including tumour necrosis factor-α, interleukin-12/23, IL-12, IL-2, and interferon-γ; while upregulating the anti-inflammatory cytokine IL-10. Its pan-immunomodulatory nature has led to its use in managing various immune-mediated dermatoses for non-FDA-approved indications.</p> <p><strong>Objectives: </strong>To review and analyze the use of Apremilast in Non-FDA-approved indications in current available literature.</p> <p><strong>Materials and methods:</strong> PubMed, EMBASE, SCOPUS, and Google scholar databases were searched with the parameters “Apremilast”, “Apremilast NOT Psoriasis*”, “Apremilast NOT Behçet’s*”, and “Apremilast NOT arthritis*”. A total of 45 relevant articles were chosen for review.</p> <p><strong>Results: </strong>We found 22 indications in dermatology where apremilast has been used without FDA approval. The best evidence was for treatment in Atopic Dermatitis, Alopecia Areata, and Hidradenitis Suppurativa, with randomized controlled trials. Prospective open-label trials were found for Cutaneous Sarcoidosis, Lichen Planus, Rosacea, and Vitiligo. Individual case series and reports were found for Acrodermatitis Continua of Hallopeau, Dermatomyositis, Disseminated Granuloma Annulare, Erythema Nodosum Leprosum, Morphea, Pityriasis Rubra Pilaris, Hailey-Hailey Disease, Recurrent Erythema Multiforme, and Folliculitis Decalvans, Prurigo Nodularis, Perforating Dermatoses, Chronic Actinic Dermatitis, and Hand Eczema, and Epidermolysis Bullosa Simplex-Generalised Severe Type. Apremilast has shown varied efficacy despite a better safety profile and tolerability over a long duration compared to conventional immunosuppressant drugs and placebo.</p> <p><strong>Conclusion: </strong>Apremilast has been used for varied non-FDA-approved indications in dermatology with variable efficacy. Better controlled, randomized studies with adequate sample size and drug comparisons are needed for better analyses.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/44700 Effectivity of Uniform Multidrug Therapy on the Success of Paucibacillary and Multibacillary Leprosy Treatment 2022-04-27T16:47:21+00:00 Prayogi Miura Susanto prayogi.miura@yahoo.com Prima Kartika Esti prima_kartika@yahoo.com Eka Komarasari ekakomarasari@gmail.com <p>Leprosy is a chronic infectious disease caused by <em>Mycobacterium leprae </em>(<em>M. leprae</em>) that involves the integumentary and peripheral nervous system, causing neuropathy, deformity, and disability. Early detection and appropriate treatment are the ways to break the chain of transmission and prevent disability in leprosy patients. The first line of treatment for leprosy is the standard Multidrug Therapy (MDT) regiment consisting of rifampicin, dapsone, and clofazimine. Standard MDT treatment is given based on the leprosy classification of paucibacillary (PB) and multibacillary (MB). The utilization of the standard MDT regiment has some limitations, particularly where there is a limited supporting test facility, causing difficulty in determining the leprosy classification accurately. An alternative regiment proposed to substitute the standard MDT is the Uniform-MDT (U-MDT). Several studies have been conducted on the use of U-MDT and have produced promising results for the treatment of PB and MB leprosy.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal https://www.nepjol.info/index.php/NJDVL/article/view/47381 Aesthetic Dermatology Training During Residency: Do we Need to Revise the Postgraduate Curriculum? 2022-08-09T16:35:35+00:00 Suchana Marahatta suchana.marahatta@bpkihs.edu Deeptara Pathak Thapa drdeeptarapathak@yahoo.com <p>Aesthetic Dermatology (AD) is a growing sub-unit of dermatology. Appearance plays a vital role in enhancing and boosting self-confidence. Reports are showing a growing demand for AD throughout the world. To converge this increasing demand, we must pivot on engendering certified competent dermatologists and hence include this sub-specialty in the dermatology residency program.</p> 2022-09-30T00:00:00+00:00 Copyright (c) 2022 Society of Dermatologists, Venereologists and Leprologists of Nepal