Authors’ reply

Sir,

We thank the readers of our article¹ for going through it in detail and for including it in a journal club discussion.²

The primary conclusions of our study were:

• Our study established the effectiveness and safety of topical timolol treatment for early (less than eight weeks old) pyogenic granuloma lesions.

• The drug has a definite role in reducing size and bleeding tendency, although complete resolution is less likely with six weeks of treatment.

• Timolol, therefore, seems a potential alternative to surgical treatment for pyogenic granulomas. Timolol’s role as an alternative to surgery needs to be further explored in forthcoming studies. Perhaps it could be tried as an adjunct, used before surgery, to shrink lesions and reduce bleeding during the same.

Our pointwise response to the correspondents’ queries and comments:

1. “In the methodology, the assessment of bleeding tendency which is graded from grade I (excellent) to grade V (no change) should have been mentioned as an assessment of improvement in the bleeding tendency.”²

   Ans: The global assessment of bleeding tendency was done both by the patients and physicians with the help of the 5-point Likert scale. Likert scale was expressed as grade 1- excellent, grade 2- very good, grade 3- good, grade 4- poor and grade 5- no change. This self-explanatory scale assesses control of the bleeding from no change to excellent control.

2. “Under the ‘Results’ section, the authors claimed that most of the pyogenic granuloma patients were males and were from rural areas. However, the clinicodemographic data tabulated [Table 1] is contradictory and depicts most patients of pyogenic granuloma to be females and from urban areas.”²

   Ans: We stand corrected; most patients were urban females. We thank our readers for minutely scrutinising both the tables and results. However, we must clarify that this change in baseline clinicodemographic detail does not alter our data analysis, results and conclusion in even the slightest manner, as this is just a satellite data.

3. “There seems to be a disparity in the sizes of images: Figure 2b appears to be of a higher magnification than Figure 2a. Also, the size of pyogenic granuloma in Figure 3b appears to be bigger than Figure 3a. Thus, clinical images are not uniform.”²

   Ans: The size of the lesion in Figure 2b is definitely larger than Figure 2a and this fact is well-appreciated in the post-treatment figure, which shows a new bulge appearing on the left side of the existing lesion. In this case, placebo was used and there was an increase in the size of the lesion, which is documented in the Figure 2b. The colour change of the granuloma is apparent in Figure 3b, which is darker than Figure 3a. Thus, the purpose of the Figures 3a and 3b to demonstrate colour change is served.

4. “We would also like to bring to your notice that in the section on “Discussion,” it is quoted that four patients had no improvement in the study done by Gupta et al.,³ whereas the original article by Gupta et al. has stated that there was no response in three patients.”²

   Ans: In the study by Gupta et al.,³ the abstract states that there was no response in three patients. However, if we follow the patient characteristics given in Table 1 of the same article, it is documented that patient no. 9, who was suffering from multiple lesions on the scalp, had no response in medium-to-large lesions, taking the count of no response to four patients. This instance has highlighted the importance of reading the full text of any article.

We hope we have clarified certain issues that our readers have had and thank them for their diligent reading. In the same breath, we also find that none of their concerns have any bearing on our results and conclusion. Since the article was criticised in a journal club, we also humbly ask the readers to go beyond reading the abstract of the referenced articles and make it a practice to go through the full articles. We also note, with due humility, the fact that there were no critical comments regarding the methodology, study design and statistical analysis of our study. We hope that our readers will include topical 0.5% timolol in the management of pyogenic granuloma, going by the evidence provided in our article.