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Indian Journal of Dermatology, Venereology, Leprology, Vol. 70, No. 1, January-February, 2004, pp. 47 Letter To Editor Hiccups following steroid oral mini-pulse (OMP) therapy Murthy SChidambara , Udagani MM Department of Skin and STDs, S. N. Medical College and H.S.K Hospital and Research Centre, Bagalkot Code Number: dv04015 Sir, Oral mini-pulse therapy (OMP) with corticosteroids has been successfully used for the treatment of alopecia areata with minimal side effects.[1] Persistent hiccups is a rare complication of oral and intravenous corticosteroid therapy.[2] We report a case who developed hiccups following betamethasone OMP, a side effect that has not been reported earlier. A 22-year-old man presented with alopecia areata on the scalp of six months′ duration. It was progressive both in terms of size and number of lesions. He gave no history of atopy, hypertension or diabetes. He had been intermittently applying various topical corticosteroids and salicylic acid and had been injected intralesional triamcinolone twice, but without any improvement. His routine hematological and biochemical tests and urine analysis were normal. He was started on 5 mg betamethasone, as a single oral dose after breakfast, on two consecutive days per week. On the second day after consuming the tablets, he reported with persistent hiccups. He was treated with antacids, domperidone 10 mg orally and injection chlorpromazine. The hiccups stopped after two days. A hiccup is a distinctive sound caused by the contraction of inspiratory muscles terminated abruptly by closure of the glottis. Brief episodes may occur due to gastric distension, a sudden change in temperature, ingestion of alcohol, excess smoking or excitement. Persistent hiccups may be due to a structural lesion or infection of the central nervous system, diaphragmatic irritation, metabolic derangement, vascular lesion, or intra-abdominal infection. Drugs, including barbiturates and sedatives, and general anesthesia may cause hiccups.[3] Hiccups have been reported as a side effect of intravenous dexamethasone cyclophosphamide pulse therapy.[4] Our patient was started on betamethasone OMP for progressive alopecia areata and subsequently developed hiccups. The sudden intake of a high dose of corticosteroids may have caused gastric irritation and hiccups. It has also been proposed that corticosteroids lower the threshold for synaptic transmission in the mid-brain and directly stimulate the hiccup reflex arc.[2] Various remedies like swallowing dry granulated sugar or vinegar; sudden pain or fright; pharyngeal irritation; breathing into a closed paper (not plastic) bag; holding the breath and increasing pressure on the diaphragm; sips of iced water; stomach washes; tongue traction; lifting the uvula with a cold spoon; and drugs like antacids, chlorpromazine, haloperidol, metoclopramide, domperidone, quinidine, phenytoin, valproic acid, nifedipine, amitriptyline and baclofen have been advocated in the management of hiccups.[5] Although a rare adverse effect of corticosteroids, hiccups can be distressing. One should be aware of this complication and its management. REFERENCES
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