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   Table of Contents - Current issue
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July-August 2020
Volume 11 | Issue 4
Page Nos. 479-681

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GUEST EDITORIAL  

Current concepts and challenges in the management of erythema nodosum leprosum p. 479
Archana Singal
DOI:10.4103/idoj.IDOJ_69_20  
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REVIEW ARTICLES Top

What is new in the pathogenesis and management of erythema nodosum leprosum p. 482
Ramesh M Bhat, Tanvi P Vaidya
DOI:10.4103/idoj.IDOJ_561_19  
Erythema nodosum leprosum (ENL) is a manifestation of type II lepra reaction, seen in lepromatous or borderline lepromatous leprosy. Although it is a common reaction encountered in clinical practice, there are an increasingly large number of newer updates in the pathophysiology and management of this condition.The treatment options have expanded far beyond just thalidomide and steroids and now extends to TNF-α inhibitors, thalidomide analogs, tenidap, cyclosporine A, plasma exchange, and even IVIG amongst others. These updates and the current knowledge of ENL are summarized in this review.
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Female pattern hair loss—An update p. 493
Yasmeen Jabeen Bhat, Najam-U- Saqib, Insha Latif, Iffat Hassan
DOI:10.4103/idoj.IDOJ_334_19  
Female pattern hair loss (FPHL) is nonscarring progressive thinning of hair with gradual decrease in the number of hair, especially in the frontal, central, and parietal scalp, due to a process known as follicular miniaturization. The etiopathogenesis of FPHL is complex with multiple factors such as genetics, inflammation, hormones, and environment playing role in it. It usually manifests as slowly progressive hair thinning, mainly over the vertex and upper parietal scalp, the frontal hairline is often spared and the miniaturization is also not as severe as in men. A thorough history, clinical examination, hair loss evaluation tests, dermoscopy, and scalp biopsy can help in establishing the diagnosis. Various biochemical tests may be needed in patients with hyperandrogenism. The treatment includes medical and surgical modalities. Topical minoxidil is still considered the first line of treatment. Along with medical therapy, cosmetic camouflage may also be needed in some cases.
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SPECIAL ISSUE ARTICLE Top

Indian association of dermatologists, venereologists and leprologists (IADVL) task force against recalcitrant tinea (ITART) consensus on the management of glabrous tinea (INTACT) p. 502
Madhu Rengasamy, Manjunath M Shenoy, Sunil Dogra, Neelakandhan Asokan, Ananta Khurana, Shital Poojary, Jyothi Jayaraman, Ameet R Valia, Kabir Sardana, Seetharam Kolalapudi, Yogesh Marfatia, P Narasimha Rao, Ramesh M Bhat, Mahendra Kura, Deepika Pandhi, Shyamanta Barua, Vibhor Kaushal
DOI:10.4103/idoj.IDOJ_233_20  
Background and Aims: Dermatophytosis has always been a common superficial mycosis in India. However, the past 6-7 years have seen an unprecedented increase in the number of patients affected by recurrent, chronic, recalcitrant and steroid modified dermatophytosis involving the glabrous skin (tinea corporis, tinea cruris and tinea faciei). Importantly, there has been a notable decrease in clinical responsiveness to commonly used antifungals given in conventional doses and durations resulting in difficult-to-treat infections. Considering that scientific data on the management of the current epidemic of dermatophytosis in India are inadequate, the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Task force Against Recalcitrant Tinea (ITART) has formulated a consensus statement on the management of dermatophytosis in India. Methods: Seventeen dermatologists with a focussed interest in dermatophytosis participated in a Delphi consensus method, conducted in three rounds. They responded as either “agree” or “disagree” to 132 statements prepared by the lead experts and gave their comments. Consensus was defined as an agreement of 80% or higher concurrence. Statements on which there was no consensus were modified based on the comments and were then recirculated. The results were finally analysed in a face-to-face meeting and the responses were further evaluated. A draft of the consensus was circulated among the participants and modified based on their inputs. Results: Consensus was achieved on 90 of the 132 statements. Direct microscopy using potassium hydroxide mount was recommended in case of diagnostic difficulty on clinical examination. Counselling of patients about strict adherence to general measures and compliance to treatment was strongly recommended as the key to successful management of dermatophytosis. A combination of systemic and topical antifungal drugs was recommended for the treatment of glabrous tinea in the current scenario. Topical corticosteroid use, whether used alone or in combination with other components, was strongly discouraged by all the experts. It was suggested that topical antifungals may be continued for 2 weeks beyond clinical resolution. Itraconazole and terbinafine were recommended to be used as the first line options in systemic therapy, whereas griseofulvin and fluconazole are alternatives. Terbinafine was agreed to be used as a first line systemic agent in treatment naïve and terbinafine naïve patients with glabrous tinea. Regular follow-up of patients to ensure compliance and monitoring of clinical response was recommended by the experts, both during treatment and for at least 4 weeks after apparent clinical cure. Longer duration of treatment was recommended for patients with chronic, recurrent and steroid modified dermatophytosis. Conclusion: Consensus in the management of dermatophytosis is necessary in the face of conventional regimens proving ineffective and dearth of clinical trials re-evaluating the role of available antifungals in the wake of evolving epidemiology of the infection in the country. It needs to be backed by more research to provide the required level of evidence. It is hoped that this consensus statement improves the quality of care for patients with dermatophytosis, which has emerged as a huge public health problem, imposing considerable financial burden on the country.
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IADVL COVID-19 SYMPOSIUMS Top

IADVL position statement and recommendations on post lockdown dermatology practice amidst the Covid -19 pandemic (IADVL Academy and IADVL Executive Committee) p. 520
Ananta Khurana, Deepika Pandhi
DOI:10.4103/idoj.IDOJ_334_20  
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Use of immunosuppressants/immunomodulators in autoimmune/inflammatory dermatologic diseases during COVID-19 pandemic—General recommendation based on available evidence p. 526
Dipankar De, Deepika Pandhi
DOI:10.4103/idoj.IDOJ_414_20  
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Safer practice of aesthetic dermatology during the COVID-19 pandemic: Recommendations by SIG aesthetics (IADVL Academy) p. 534
Gulhima Arora, Sandeep Arora, Abhay Talathi, Rajat Kandhari, Vineeta Joshi, Sonali Langar, Smita Nagpal, Vinma H Shetty, Rakhee V Nair, Divya Sharma, Rashmi Sharma, Prateek Sondhi
DOI:10.4103/idoj.IDOJ_328_20  
The COVID-19 pandemic caused by the SARS-CoV-2 virus, has changed the homeostasis of the medical world. In this critical phase, in addition to the general recommendations issued by World Health Organization (WHO) for medical practitioners and health care givers, certain other precautions and safe care practices need to be emphasized which are unique to each branch of medicine. Aesthetic dermatology is no exception. With aesthetic treatments on the rise, it is pertinent to formulate safe practices for aesthetic dermatology to protect the doctor, health staff and the patients from getting exposed during this phase and in the aftermath of the pandemic. Recommendations for surgical and dental procedures advice to defer such procedures. This can be extrapolated to aesthetic dermatology also, but once health care services start, there should be some safety recommendations to be followed until we have definitive management or a vaccine for it.
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Hand hygiene practices and risk and prevention of hand eczema during the COVID-19 pandemic p. 540
Rashmi Jindal, Deepika Pandhi
DOI:10.4103/idoj.IDOJ_448_20  
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ORIGINAL ARTICLES Top

A prospective study examining trigger factors and hormonal abnormalities in adult female acne p. 544
Prekshi Bansal, Kabir Sardana, Gauri Vats, Lokesh Sharma, Umesh Chandra Garga, Ananta Khurana
DOI:10.4103/idoj.IDOJ_500_19  
Background: Numerous triggers have been implicated in adult female acne including endogenous (hormonal dysfunction and genetic predisposition) and exogenous causes (drugs, cosmetics, sunscreens, stress, and smoking). Aims: To evaluate the role of various trigger factors in adult female acne and to analyze the androgenic hormone pattern including anti-Mullerian hormone (AMH) in these patients. Materials and Methods: Patients having acne of age ≥25 years were analyzed using a pre devised proforma to elicit trigger factors while the severity was graded using the Global Acne Grading System (GAGS). A detailed hormonal assessment was undertaken that assessed total testosterone (TT), sex hormone-binding globulin (SHBG), free androgen index (FAI), AMH, 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), and prolactin. Results: Out of the 165 cases seen and sub-analyzed for triggers, premenstrual flare, diet, cosmetics, and stress were the most commonly implicated causes. Among cosmetics, fairness creams and foundations were implicated.The hormonal analysis revealed deranged values of all hormones with the most common being 17-OHP and AMH. Almost 42.8% patients with DHEAS derangement and 58.75% females with raised 17-OHP suffered from moderate to severe stress. Limitations: A prospective cohort correlation study of the implicated triggers is needed to confirm the association with adult female acne. Conclusions: Adult female acne may be triggered by diet, stress, and cosmetics and there is a distinct hormonal milieu that accounts for hyperandrogenemia. We noted high levels of adrenal androgens which have been known to be associated with stress and sleep deprivation. Our study shows the value of counseling adult female acne patients about various acne triggers.
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Hair styling procedures and hair morphology: A clinico-microscopic comparison study p. 551
Ram H Malkani, Seema M Shirolikar, Suman Karmakar, Maninder Singh Setia
DOI:10.4103/idoj.IDOJ_452_19  
Background: The present study is a cross-sectional comparison to evaluate the association between hair loss and hair structural changes (gross and microscopic), and hairstyling procedures in women. Methods: We included 94 women; and collected data on sociodemographics, clinical history, sun-exposure, and hair-product use history. Women who reported blow drying of hair, hair straightening, use of hair iron or perming in the past 6 months were classified as cases. Age matched (±2 years) women who did not report any of the above procedures in the past 6 months were controls. The following tests were done: hair pull test; hair density assessment; hair breakage index (HBI); and microscopic examination. A logistic regression model was used for estimation of the odds ratio (OR) and 95% confidence intervals (CI). Results: The mean (standard deviation [SD]) age in the case and control group was 26.4 (6.3) and 27.4 (6.3) years, respectively (P = 0.43). There was no significant difference in the mean (SD) HBI (1.05 [0.08] vs 1.07 [0.05], P = 0.22) or hair density (3.28 [0.41] vs 3.16 [0.39], P = 0.19). Cases were significantly more likely to have microscopic changes compared with controls (OR: 22.0, 95% CI: 4.3, 112.6; P < 0.001). Sun exposure for more than 3 h was significantly associated with microscopic changes (OR: 6.7, 95% CI: 1.2, 39.1; P = 0.03). Conclusion: Women with hairstyling procedures in the past 6 months were more likely to have microscopic changes, even though there was no difference in the hair assessment parameters. Specific guidelines on use of hairstyling procedures for Indian hair should be developed.
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A study to evaluate the role of intradermal and intralesional measles, mumps, rubella (MMR) vaccine in treatment of common warts p. 559
Pragya Gupta, Geeta Ram Tegta, GK Verma, Abhishek Gupta, Mudita Gupta, Shikha Sharma
DOI:10.4103/idoj.IDOJ_144_19  
Background: Warts are common cutaneous viral infection with a wide range of therapeutic modalities. Various agents have been tried for immunotherapy in warts. Objectives: Determine the role of intralesional and intradermal measles, mumps, rubella (MMR) vaccine in the treatment of common warts; to compare the efficacy of intralesional versus intradermal MMR vaccine. Methods and Materials: Patients diagnosed with verruca vulgaris were divided into two groups. In study group A, the individuals were injected with an intralesional MMR vaccine of 0.3 mL in the representative wart (largest) once in 3 weeks till there is complete clearance or maximum of four injections whichever is earlier, while in study group B, the individuals were injected with an intradermal MMR vaccine of 0.3 mL over the unilateral deltoid muscle area at similar intervals. Results: There were 33 patients in each group. In group A, 10 (30.3%) patients showed complete, 9 (27.3%) marked, 6 (18.2%) moderate, 3 (9.1%) mild, and 5 (15.2%) no response. In group B, seven (21.2%) patients showed complete, one (3.0%) marked, one (3.0%) moderate, four (12.1%) mild, and 20 (60.6%) no response. There were minimal side effects in the form of pain, erythema, itching at the injection site in a few patients, only one patient had syncope. Conclusion: We conclude that the MMR vaccine is an effective and safe modality of treatment for verruca vulgaris without any serious adverse effects. Also, the intralesional route showed better results in comparison to the intradermal route when we consider the treatment of a representative wart.
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Skin barrier function defect - A marker of recalcitrant tinea infections p. 566
Puneet Bhargava, Shivi Nijhawan, Heena Singdia, Taniya Mehta
DOI:10.4103/idoj.IDOJ_434_19  
Context: Recently, there has been an increase in the number of chronic, recurrent, and recalcitrant dermatophytosis. Many factors implicated are barrier defects, aberrant host immune response, application of steroids or other irrational combination creams, transmission within family, occlusive clothing, poor hygienic conditions, poor compliance, drug resistance and virulence of the infecting strain. Transepidermal water loss (TEWL) is an important index in accessing the barrier function of skin. Aim: To ascertain the role of TEWL from the lesional skin and its effect on the cure rate and relapse in patients of tinea cruris. Materials and Method: A hospital based prospective comparative study was conducted for 1 year. A total of 200 patients of tinea cruris diagnosed clinically and by KOH examination, were included in the study. TEWL was calculated using Tewameter TM300 open chamber probe of Courage and Khazaka, Cologne, Germany. Patients were classified according to the TEWL values into Group A (patients with abnormal TEWL) and Group B (normal TEWL). Both groups were given oral itraconazole and antihistamines for 4 weeks. The cure rates and recurrence rates of both the groups were analyzed and compared. Results: In the Group A, i.e., patients of tinea cruris with abnormal TEWL, only 28% of the patients showed clinical improvement at the end of 1 month. Out of those cured, 78.57% of the cases showed recurrence after 2 months of completion of therapy. In Group B, i.e., patients of tinea cruris with normal TEWL, 69% (n = 69) of the patients showed clinical improvement at the end of 1 month. Out of those cured, only 21.74% of the cases (n = 15) showed recurrence. Conclusion: The cases of tinea cruris with abnormal TEWL show significant decrease in cure rates and significant relapse rates among those initially cured.
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Study of ocular manifestations of Stevens-Johnson syndrome/toxic epidermal necrolysis p. 570
Arundha Abrol, Anirudha Gulanikar, Snehal Thakre, Asim Patel
DOI:10.4103/idoj.IDOJ_377_19  
Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) represent different ends of the spectrum of the same clinical entity causing severe mucocutaneous reactions, usually to drugs, characterized by intraepidermal cell death leading to blistering and epidermal sloughing. The severe cutaneous manifestations of this disease spectrum may often lead to overlooking of the ocular sequelae, which are very common and may lead to loss of visual acuity. Aim: The present research is an attempt to study the ocular manifestations seen in association with SJS/TEN. Materials and Methods: Patients having ocular manifestations of SJS/TEN attending the outpatient and inpatient department of skin and VD in a tertiary care hospital, were included in the study. Ophthalmologic examination of all patients was observed and recorded. Results: A total of 30 patients were included in the study. Among all, 27 patients had ocular involvement and among them 7 patients (25.9%) had mild, 17 patients (62.9%) had moderate, and 3 patients (11.1%) had severe ocular manifestations. Corneal involvement was found in 12 patients (44.4%), conjunctival involvement was found in 22 patients (81.4%), and eyelid involvement was found in 20 patients (74.0%). All patients were managed medically.
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BRIEF REPORTS Top

Comparison of platelet-rich plasma prepared using two methods: Manual double spin method versus a commercially available automated device p. 575
Vishal Gupta, Anita S Parihar, Mona Pathak, Vinod K Sharma
DOI:10.4103/idoj.IDOJ_653_19  
Background: In the absence of a standard protocol, several methods and devices have been used for preparing platelet-rich plasma (PRP) with varying platelet concentrations. Methods: Venous blood sample from 20 patients was used for preparing PRP using two methods: a manual double-spin method (1st spin at 160 g × 10 min, 2nd spin at 400 g × 10 min), and using a commercially available automated device (DrPRP-Kit®, REMI Laboratory Instruments). Platelet, erythrocyte, and total leukocyte counts were calculated for each PRP sample and compared. Results: Platelet count in the PRP prepared with the manual double-spin method (PRPm, 12.51 ± 5.89 × 105/μL) as well as with the automated device (PRPa, 7.25 ± 4.74 × 105/μL) had significantly higher mean platelet count than whole blood (2.58 ± 0.81 × 105/μL, P < 0.001). The mean platelet count in PRPm was statistically significantly higher than PRPa (P < 0.001). The platelet capture efficiency of the manual method (mean 47.11%, median 41.75%) was statistically significantly higher than that of the automated device (mean 31.89%, 29.51%, P = 0.012). Platelet counts in both PRPs were variable, but the counts were more dispersed in PRPa(coefficient of variation 65%) as compared to PRPm(coefficient of variation 47%). Conclusion: The manual double-spin method had a higher platelet capture efficiency resulting in a higher platelet concentration as compared to the automated device. Though there was a significant interindividual variation in the platelet yield in the PRPs produced by both methods, results were more consistent with the manual method.
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Sonographic evaluation of subclinical enthesopathy in patients of chronic plaque psoriasis p. 580
Kapil Vyas, Suresh K Jain, Asit Mittal, Ramesh Kumar, Sangeeta Saxena, Sourabh Malviya
DOI:10.4103/idoj.IDOJ_446_18  
Background: Psoriasis is associated with spondyloarthropathy in 10%–30% of cases. Enthesitis is major feature of psoriatic arthritis. Ultrasonography can detect subclinical entheseal abnormalities in psoriasis patients. Objectives: To determine the prevalence of subclinical enthesopathy in psoriasis vulgaris using ultrasonography and evaluating its correlation with severity and duration of psoriasis. Materials and Methods: This study included 50 patients of psoriasis vulgaris and 50 healthy controls. Sonographic evaluation of six sites bilaterally (proximal plantar fascia, distal Achilles tendon, distal and proximal patellar ligaments, distal quadriceps, and brachial triceps tendons) were done in each subject. All Ultrasonographic findings were identified according to MASEI (Madrid sonography enthesitis index). Enthesopathy scores of patients and controls were compared and receiver operating characteristic curve was used to determine cut off value of MASEI, above which ultrasound enthesitis of clinical significance could be diagnosed. Results: 31 (62%) psoriasis patients had subclinical enthesopathy of clinical significance as compared to only 5 (10%) of controls. Mean MASEI score between psoriasis cases and control was statistically different, 12.72 ± 7.55 (Mean ± SD) and (5.14 ± 4.69), respectively (P value 0.000001).The receiver operating characteristic curve established an ultrasound score of >11 as the best cut-off to differentiate between subject with enthesopathy of clinical significance from those with enthesopathy of unknown significance. No statistically significant correlation was found between the degree of enthesopathy (MASEI score) and duration and severity of the psoriasis. Conclusion: Ultrasonography can effectively screen subclinical entheseal abnormalities in psoriasis patients.
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Role of histopathology in predicting type 1 lepra reaction in borderline tuberculoid leprosy p. 586
Dhanya Sankaran, Sarita Sasidharanpillai, Kidangazhiyathmana Ajithkumar, Aparna Govindan, Ekkila Valappil Seemi, Puthen Parambath Sathi
DOI:10.4103/idoj.IDOJ_423_19  
Context: Lepra reactions if not managed promptly are an important cause of sudden onset nerve palsy and disability due to leprosy. Aim: To evaluate the usefulness of histology in predicting type 1 lepra reaction. Setting and Design: After obtaining clearance from institutional research and ethics committees, all histologically proven borderline tuberculoid patients diagnosed at our center from 1.8.2016 to 31.7.2018 were included in this retrospective cross-sectional study. Method: Clinical details were collected from patient records. The pathologist who was blinded to clinical evidence of type 1 lepra reaction at the time of biopsy re-evaluated the histopathology slides for evidence of type 1 reaction. The data of individual patient was analyzed to identify those who had a type 1 reaction at the time of the biopsy or who developed a lepra reaction during follow up. Statistical Analysis Used: Association between histological evidence of type 1 reaction and clinical manifestation of the same subsequently, was assessed using Pearson's Chi square test. Results: Study group comprised of 22 females and 18 males. Clinicohistological concordance was noted in 27 patients (67.5%). Subclinical type 1 reaction was documented in 11 patients (27.5%) based on histopathology evaluation. Five (45.5%) of these 11 patients subsequently developed clinical features of type 1 reaction. This was found to be statistically significant (P value 0.02). Limitations: Main limitation was the small sample size. Conclusions: Histology could serve as a useful tool in predicting future type 1 lepra reaction.
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Periorbital acquired dermal macular hyperpigmentation: A distinctive clinical entity in young adults—Observational case-control study p. 590
T Muhammed Razmi, Vishal Thakur, Keshavamurthy Vinay, Divya Aggarwal, Bishan D Radotra, Muthu Sendhil Kumaran, Davinder Parsad
DOI:10.4103/idoj.IDOJ_415_19  
Introduction: Acquired dermal hyperpigmentation (ADMH) presenting on periorbital region has been described as individual case reports. We tried to characterize the features of periorbital ADMH. Materials and Methods: This was a retrospective case-control study among our patients who attended the pigmentary clinic during January 2016–December 2017. Clinical, dermoscopic, and histopathological features of subjects who were recruited during the study period were prospectively evaluated. Results: Total 19 subjects (11%) were identified among 177 ADMH patients. Periorbital ADMH patients had a relatively younger age of onset (23.26 ± 11.06 vs. 36.16 ± 13.41, P < 0.001). Dermoscopy of early periorbital ADMH showed only imperceptible speckled blue-gray dots that accentuated at outer-corner creases of eyes (the “outer-corner crease sign”). Clinicopathological features and prognosis of periorbital ADMH were similar to that of ADMH per se. Conclusion: Periorbital ADMH should be considered as a differential diagnosis of periorbital hyperpigmentation in children and young adults. Outer-corner crease sign on dermoscopy may help to rule out other differentials in its early presentation.
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To evaluate the role and relevance of cytokines IL-17, IL-18, IL-23 and TNF-α and their correlation with disease severity in chronic urticaria Highly accessed article p. 594
Preeti Sharma, Praffula K Sharma, Anubhuti Chitkara, Seema Rani
DOI:10.4103/idoj.IDOJ_396_19  
Introduction: The basic event in the pathogenesis of urticaria is inappropriate activation and degranulation of dermal mast cells. Cytokines are soluble polypeptide mediators that play a key role in immunological, inflammatory and reparative host responses including chronic urticaria. Objective: The aim of this study was to evaluate the role and relevance of cytokines interleukin-17 (IL-17), interleukin-18(IL-18), interleukin-23(IL-23) and tumor necrosis factor-alpha (TNF-α) and their correlation with disease severity in patients with chronic urticaria. Materials and Methods: A prospective cross-sectional study was conducted to measure the serum concentration of IL-17, IL-18, IL-23 and TNF-α in 50 chronic urticaria patients and in 30 healthy controls. Disease activity was assessed by using urticaria activity score (UAS). Results: Serum concentration of IL-17, IL-18, IL-23 and TNF-α were significantly higher during the acute episode in chronic urticaria patients as compared with the healthy control subjects (mean: 1.84 ± 0.81 vs 0.03 ± 0.02 pg/ml; P < 0.001, 501.41 ± 208.98 vs 218.39 ± 39.83 pg/ml; P < 0.001; 25.57 ± 10.79 vs 0.15 ± 0.14 pg/ml, P < 0.001; and 455.54 ± 253.54 vs 8.498 ± 3.644 pg/ml, P < 0.001, respectively). There was a significant positive correlation between serum levels of IL-17, IL-18, IL-23 and TNF-α and severity of disease. Conclusion: The serum levels of IL-17, IL-18, IL-23 and TNF-α were raised in patients of chronic urticaria and positively correlated with the severity of urticaria.
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COMMENTARY Top

Cosmetic trichology: Hair cosmetics, styling, and their effect on the hair fiber! p. 598
Aseem Sharma, Madhulika Mhatre
DOI:10.4103/idoj.IDOJ_621_19  
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CASE REPORTS Top

A rare case of cutaneous onchocerciasis in North-East India, review of literature p. 600
MM Pasha, Chetan C Patil, M Tanuja, Debdeep Mitra
DOI:10.4103/idoj.IDOJ_555_19  
Onchocerca volvulus is a spirurid nematode that mainly affects the rural poor of Sub-Saharan Africa, Yemen, and parts of Central and South America. River blindness caused by Onchocerca volvulus is considered to be the second most common infectious cause of blindness worldwide. We report a rare case of cutaneous Onchocerciasis from a non endemic area of North-East India. We could extract live adult worms from the subcutaneous lesions and also micro filariae from the skin nips. Onchocerca was confirmed based on its morphology. The patient has been subjected to therapy with ivermectin and doxycycline and is currently on regular follow up.
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Progressive osseous heteroplasia: A rare case report p. 604
Kananbala Sahu, Arpita N Rout, Liza Mohapatra, Prasenjeet Mohanty
DOI:10.4103/idoj.IDOJ_502_19  
Progressive osseous heteroplasia (POH) is a rare genetic condition of progressive extraskeletal bone formation. POH is clinically suspected by cutaneous ossification, usually presenting in early life, that involves subcutaneous and then subsequently deep connective tissues, including muscle and fascia. We report a case of POH in a 3-year-old child with multiple nontender subcutaneous nodules which, on radiology and histopathology, showed intracutaneous bone formation. Although there is no specific and effective treatment, knowledge about this entity is necessary for early detection and genetic counseling of parents.
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Complete remission in a patient with treatment refractory bullous pemphigoid after a single dose of omalizumab p. 607
Surabhi Sinha, Diksha Agrawal, Kabir Sardana, Anita Kulhari, Purnima Malhotra
DOI:10.4103/idoj.IDOJ_438_19  
Bullous pemphigoid (BP) is an autoimmune disorder known to be mediated by immunoglobulin G (IgG) autoantibodies. The role of immunoglobulin E (IgE) antibodies is being investigated as their presence has been described in severe cases. Herein, we report a patient of BP who was refractory to most conventional agents and developed hypotension after rituximab but achieved lasting remission after a single dose of the anti-IgE monoclonal antibody omalizumab.
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Cutaneous histoplasmosis: An unusual presentation with nasal obstruction Highly accessed article p. 612
Surabhi Sinha, Diksha Agrawal, Kabir Sardana, Purnima Malhotra
DOI:10.4103/idoj.IDOJ_422_19  
Histoplasmosis is a systemic fungal disease that may be presented with a variety of clinical manifestations, usually as an opportunistic infection in immunocompromised individuals. We present an HIV seropositive patient with a large fleshy growth causing left-sided nasal obstruction, as an unusual presentation. The lesions shrunk dramatically and almost completely on intravenous amphotericin-B lipid complex (ABLC) given for 2 weeks followed by long-term oral itraconazole.
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A rare presentation of concurrent onset and coexistence of generalized lichen planus and psoriasis in a child Highly accessed article p. 616
Sunmeet Sandhu, Preema Sinha, Divya Shelly, Siddharth Bhatt
DOI:10.4103/idoj.IDOJ_459_19  
Independently, psoriasis and lichen planus (LP) are common inflammatory skin conditions affecting around 2–3% and 1% of the population, respectively. However, the coexistence of both diseases is rare. Common immunological mechanisms with altered T-cell-mediated autoimmunity, cytokine milieu, and Koebner phenomenon play a role in their pathogenesis. As reviewed in the literature, psoriasis may independently be associated with other autoimmune conditions like vitiligo, alopecia areata, LP, and discoid lupus erythematosus. A rare co-occurrence of these two or three autoimmune diseases has been reported. Here, we report a case of a 10-year-old boy who presented with persistent nonpruritic multiple hyperpigmented scaly papules and plaques over the body since 6 months of age. Histopathology revealed features suggestive of both LP and psoriasis in the same section. A diagnosis of psoriasis–LP overlap was made, and the patient was managed with tab acitretin 25 mg daily and narrowband ultraviolet B (NBUVB) phototherapy with which he showed satisfactory clearance of the lesions.
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Transient symptomatic zinc deficiency in a breastfed infant associated with low zinc levels in maternal serum and breast milk improving after zinc supplementation: An uncommon phenotype? Highly accessed article p. 623
Sanket Vashist, Ashwani Rana, Vikram K Mahajan
DOI:10.4103/idoj.IDOJ_386_19  
Acrodermatitis enteropathica (AE) is a rare, autosomal-recessive disorder of neonatal zinc deficiency due to SLC39A4 (intestinal zinc transporter, Zip4) gene mutation with onset after weaning while breastfeeding during this period will be protective. Transient symptomatic zinc deficiency is also acquired rarely in breastfed infants with increased zinc requirements and/or inadequate concentration of zinc in breast milk. The nursing mothers of transient symptomatic zinc deficiency infants show SLC30A2 (mammary epithelial zinc transporter, ZnT-2) gene mutation and abnormally low zinc levels in the breast milk despite normal serum zinc levels, which do not improve after zinc supplementation. A 2-month-old breastfed male infant had AE-like clinical features of zinc deficiency for two weeks. His symptoms and low serum zinc levels improved rapidly after zinc supplementation. The mother also had low serum and breast milk zinc concentration and both improved after oral zinc therapy indicating a non-heritable phenotype. The relevant literature is reviewed and significance of dietary zinc supplementation during pregnancy/lactation is emphasized.
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CONCISE COMMUNICATIONS Top

Congenital melanocytic kissing nevus on right eyelid - A rare phenomenon p. 627
Rita V Vora, Aishni J Shah, Trisha B Patel
DOI:10.4103/idoj.IDOJ_481_19  
Congenital divided melanocytic nevus is a rare form of melanocytic nevus, which presents in the upper and lower eyelids on one side. It comes to existence due to genetic alteration in cells, which arise from mosaicism and only 30 cases have been reported till now. We present a rare case of 66 years old female with kissing nevus on right eyelids with no ophthalmological or functional disturbances.
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Dermatitis artefacta presenting as dermatomyositis: A diagnostic conundrum p. 629
Annie Raizada, Maitreyee Panda, Nibedita Dixit, Trashita Hassanandani
DOI:10.4103/idoj.IDOJ_594_19  
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A masquerading solitary skin lesion: Unusual presentation of multibacillary leprosy with dermoscopic assistance in diagnosis p. 632
Naveen Kumar Kansal, Prashant Pranesh Joshi, Aditi Dhanta, Neirita Hazarika, C Divyalakshmi
DOI:10.4103/idoj.IDOJ_495_19  
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Dasatinib-induced perforating folliculitis in a bone marrow transplant patient p. 635
Nagendran Prabhakaran, Pallerla Sri Divya, Sivaranjini Ramassamy, Debasis Gochhait
DOI:10.4103/idoj.IDOJ_592_19  
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Lipoid proteinosis: Curious case of two siblings! p. 639
Pooja Agarwal, Ashish Jagati, Priyanka Vadher, Malay Chaudhari
DOI:10.4103/idoj.IDOJ_611_19  
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Fixed drug eruption to palm wine: A case p. 641
Ashish Jagati, Pooja Agarwal, Pooja Moliya, Sabha Neazee
DOI:10.4103/idoj.IDOJ_504_19  
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LETTERS TO THE EDITOR Top

Penile metastases from lung squamous cell carcinoma presenting as an initial manifestation p. 643
Takako Miura, Toshiyuki Yamamoto
DOI:10.4103/idoj.IDOJ_375_19  
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Pleuri-segmental ipsilateral nonsyndromic infantile hemangioma responding favorably to oral propranolol p. 645
Raihan Ashraf, Rahul Mahajan, Sanjeev Handa, Dipankar De
DOI:10.4103/idoj.IDOJ_455_19  
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Isolated scalp lesions of molluscum contagiosum—Report of three cases p. 648
M Sivasankari, Preema Sinha, Subramaniyan Radhakrishnan
DOI:10.4103/idoj.IDOJ_454_19  
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Dermatosis due to steroid exposure: A startle in occupational hazard p. 651
Pragya Ashok Nair, Anuj Bhut, Trisha Patel
DOI:10.4103/idoj.IDOJ_468_19  
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The scourge of predatory journals p. 653
Ranesh Kumar, Rohit Bhoil, Rohan Bhoil
DOI:10.4103/idoj.IDOJ_479_19  
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Angiokeratoma circumscriptum on the breast: A case with unusual features p. 655
Anuva Bansal, Tanvi Gupta
DOI:10.4103/idoj.IDOJ_472_19  
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Petechiae over face: A case of rumpel-leede phenomenon Highly accessed article p. 658
Hania Qamar Khan, Mohammad Adil, Syed Suhail Amin, Mohammad Mudassir
DOI:10.4103/idoj.IDOJ_441_19  
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DERMATOLOGY PEARLS Top

A simple and effective therapeutic approach to lichen simplex chronicus p. 660
Binod K Khaitan, Savera Gupta
DOI:10.4103/idoj.IDOJ_258_19  
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SKINDIA QUIZ Top

Firm, painless nodule over the cheek p. 662
Reenu Mariam George, Remya Rajamohanan, Sheela Kuruvila, Satyaki Ganguly
DOI:10.4103/idoj.IDOJ_92_19  
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Chronic anogenital ulceration p. 665
Ömer Kutlu, Fatma Nur Kutlu, Yücel Tekin
DOI:10.4103/idoj.IDOJ_121_19  
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CLINICOPATHOLOGICAL CHALLENGE Top

Erythematous indurated plaque on the chin in an elderly man p. 667
Krati Mehrotra, Geeti Khullar, Charvi Chanana, Meetu Agrawal
DOI:10.4103/idoj.IDOJ_549_19  
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THROUGH THE LENS Top

Focal facial dermal dysplasia type 4 Highly accessed article p. 670
Piyush Kumar, Anupam Das
DOI:10.4103/idoj.IDOJ_347_19  
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A case of eruptive pseudoangiomatosis: Clinical, histopathological, and dermoscopic findings Highly accessed article p. 672
Ramesh K Kushwaha, Alpana Mohta, Suresh K Jain
DOI:10.4103/idoj.IDOJ_407_19  
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THROUGH THE DERMOSCOPE Top

Dermoscopy of paget's disease p. 674
Yasmeen J Bhat, Safia Bashir, Rohi Wani, Iffat Hassan
DOI:10.4103/idoj.IDOJ_64_19  
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Unusual dermoscopic features in a patient with alopecia areata p. 676
Feroze Kaliyadan, Abdulaziz Alkhateeb, Krishna Swaroop, Abdulrahim Abdulsalam Alabdulsalam
DOI:10.4103/idoj.IDOJ_489_18  
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Importance of dermoscopy to diagnose vulvar vestibular papillomatosis vs. warts Highly accessed article p. 680
Sampada Avinash Thakare, Satish Udare
DOI:10.4103/idoj.IDOJ_463_18  
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