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   Table of Contents - Current issue
March-April 2020
Volume 11 | Issue 2
Page Nos. 135-300

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Update on management of morphea (Localized Scleroderma) in children p. 135
Renu George, Anju George, T Sathish Kumar
Juvenile localized scleroderma (morphea) is the predominant scleroderma in childhood which affects the skin and may extend to the underlying fascia, muscle, joints and bone. The assessment of activity and damage can be done with a validated instrument like LoSCAT. Disease classified as “low severity” which includes superficial plaque morphea can be treated with topical mid potent- potent steroids, tacrolimus, calcipotriol or imiquimod in combination with phototherapy. Methotrexate is recommended for linear, deep and generalized morphea. Steroids are effective in the early inflammatory stage and used in combination with methotrexate. Methotrexate is continued for at least 12 months after adequate response is achieved. Mycophenolate mofetil is given in cases where methotrexate is contraindicated or for those who do not respond to methotrexate. There are also reports of improvement of disease with ciclosporine and hydroxychloroquine. In severe cases, recalcitrant to standard therapy there may be a role for biologics, JAK inhibitors, and IVIG. Supportive measures like physiotherapy and psychiatric counseling are also important in the management of morphea. Orthopedic surgery and other measures like autologous fat transfer may be advocated once the disease is inactive.
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Dermoscopic pigment network: Characteristics in non-melanocytic disorders Highly accessed article p. 146
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit
Brown-black pigment network is the hallmark dermoscopic feature of melanocytic lesions. Several non-melanocytic disorders also exhibit a pigment network as one of their main or useful dermoscopic diagnostic features. This article presents a compilation of such disorders to the readers describing their essential dermoscopic features with an emphasis on the characteristics of the pigment network exhibited by them.
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A study of quality of life in patients with facial melanoses p. 154
Leena Raveendra, Harsha Sidappa, Sapna Shree
Context: Facial melanoses decreases the quality of life (QoL). Melasma is the commonest cause but there are various other etiologies for facial pigmentation. Aims: To study the clinical profile of patients with facial melanoses and the psychological burden in these patients. Settings and Design: All patients having patchy or diffuse facial pigmentation attending the OPD in a tertiary care hospital for a period of 1 year were included in this hospital based cross-sectional study. Subjects and Methods: The type, extent, and distribution of the pigmentation was noted and tabulated in all patients. All patients were explained about Skindex-16 questionnaire and asked to complete it. Statistical Analysis Used: Student t-test (two tailed, independent) was used to find the significance of study parameters on continuous scale between two groups. Chi-square/Fisher Exact test was used to find the significance of study parameters on categorical scale between two or more groups. Correlation was performed using Spearman corrélation. Results: The total number of cases studied was 238 of which 186 (78.2%) were females and 52 (21.8%) were males. The most common diagnosis was melasma seen in 73% of cases. Other conditions noted were phototanning (5.8%), post-inflammatory hyperpigmentation (5.8%), Lichen planus pigmentosus (4.2%), freckles (3.7%), and Nevus of Ota (1.6%). Skindex-16 score against different grades of pigmentation showed that the mean Skindex-16 score was higher in severe cases but there was no statistically significant difference between the groups. Conclusions: The extent and severity of facial pigmentation and the decrease in the QoL are not proportional.
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Cardiovascular and metabolic risk assessment in patients with lichen planus: A tertiary care hospital-based study from Northern India p. 158
Sabha Mushtaq, Devraj Dogra, Naina Dogra, Jonathan Shapiro, Kaniz Fatema, Nafis Faizi, Gunjan Gupta
Background: The association between lichen planus (LP) and cardiovascular disease (CVD) risk factors has been demonstrated in previous reports. However, the evidence of CVD risk factors in Indian patients with LP is limited. Objective: To compare CVD risk factors in LP patients and healthy controls. Methods: We performed a cross-sectional study on 122 subjects, 61 LP patients, and 61 controls who visited the outpatient clinic of the dermatology department of a tertiary care hospital. Patients with skin diseases known to be associated with CV risk, pregnant, and lactating women were excluded from the study. CVD risk factors were compared between LP cases and controls using anthropometric measures, hemodynamic and metabolic parameters, and inflammatory marker (ESR). Results: The proportion of metabolic syndrome (MS) was significantly higher in LP patients than the controls (29.5% vs. 9.8%, odds ratio [OR] 3.83; 95% confidence interval [CI] 1.40–10.50; P = 0.006). The proportion of dyslipidemia was also significantly higher in LP patients (70.5% vs. 42.6%; P = 0.002). LP patients had a high proportion of obesity (P = 0.004), hypertension (P = 0.004), impaired fasting glucose (P = 0.025), and raised ESR (P = 0.006) as compared to controls. A multivariate regression model demonstrated that dyslipidemia and obesity were significantly associated with LP even after controlling for confounders such as age, gender, sedentarism, dietary habits, alcohol, and impaired fasting glucose. There was no significant association between the extent of LP and the proportion of MS or dyslipidemia. Conclusion: The present study found a significant association of LP with individual CVD risk factors as well as MS.
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Molecular identification and quantification of malassezia species isolated from pityriasis versicolor p. 167
Prasanna Honnavar, Sunil Dogra, Sanjeev Handa, Arunaloke Chakrabarti, Shivaprakash M Rudramurthy
Background: Pityriasis versicolor (PV) is the most common chronic superficial infection of the stratum corneum, reported in 40–60% of the tropical population. After the description of the new Malassezia species, only a few studies have been conducted from India. Aims: Molecular identification, quantification of Malassezia species implicated with PV and correlation to its clinical presentation. Materials and Methods: The subjects include 50 PV patients, who attended the dermatology outpatient department of our hospital and 50 healthy individuals. Same size area of the skin was sampled from lesional and non-lesional sites in the patient group and from forehead, cheek, and chest of healthy individuals. Malassezia spp. isolated were identified by conventional method and confirmed by ITS2 PCR-RFLP and sequencing of D1/D2 region of 26S rDNA. Results: Eighty percent of patients presented with hypopigmented lesions and 20% with hyperpigmented lesions. From PV lesions, the most frequently isolated species was M. furfur (50%), followed by M. globosa (27.3%), mixture of M. furfur and M. globosa (15.9%), M. sympodialis (4.5%), and M. slooffiae (2.3%). Higher Malassezia density was found in lesional area as compared to non-lesional area of PV patients and in healthy individuals (P 0.0001). Conclusion: Although M. furfur was the most prevalent species isolated from both patients and controls, significantly higher isolation of M. globosa from the lesional area compared to non-lesional area indicates its possible role along with M. furfur in causing PV.
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Intra-operative dermoscopy in assessment of melanonychia and as a guide for biopsy p. 171
Ishmeet Kaur, Sundeep Chowdhry, Paschal D'Souza, Deepak Jakhar, Mukesh Kumar Yadav, Onkar Kaur
Background and Aims: Melanonychia can be a manifestation of benign or malignant pathology and often poses a diagnostic challenge on clinical examination. Even with distinguishing dermoscopic features (nail plate), it can be quite difficult to determine the nature of pigmentation as complete assessment of nail bed and matrix is still not possible. Intraoperative dermoscopy (IOD) can serve as a useful tool to appreciate the bed and matrix changes. The aim here is to study the intraoperative dermoscopic features in patients with melanonychia and correlate with histopathology. Methods: 20 consecutive patients with melanonychia were recruited. Inclusion criteria was melanonychia of sudden onset, progressive nature, irregular width/color/symmetry on dermoscopy, positive Hutchinson sign, solitary nail involvement or associated nail dystrophy. Preoperative dermoscopy was performed and recorded. Patients were planned for nail matrix biopsy, during which IOD was performed over nail matrix and bed after removal of the nail plate. Images were recorded and analyzed and correlated with the histopathology. Results: Out of 20 patients, 12 were females and 8 males. On IOD-histopathological correlation, 2 patients were found to have melanoma of the nail unit, 5had nail lichen planus, 9 had benign melanocytic nevi, and 4 had fungal melanonychia. IOD revealed fine, parallel and regular lines of pigmentation localized to proximal nail bed and matrix in all patients with benign melanonychia, while dark thick bands with irregular borders, dots, globules, streaks and structureless areas in the two patients with melanoma. Fungal melanonychia revealed an unremarkable nail bed and matrix on IOD. Conclusion: Intraoperative dermoscopycan help in determining the nature of melanonychia and obviate the need to perform biopsy in certain cases. It can also aid in delineating the most suitable site for biopsy, along with grossly assessing the extent of involvement in case of malignancy.
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Spectrum of cutaneous adverse drug reactions to anti-tubercular drugs and safe therapy after re-challenge - A retrospective study p. 177
Reena K Sharma, Ghanshyam K Verma, Gita Ram Tegta, Samriti Sood, Renu Rattan, Mudita Gupta
Background: Tuberculosis (TB) is a major global health problem and leading cause of death. Anti-tubercular therapy (ATT) can lead to various adverse effects including cutaneous reactions. Re-challenge remains the only option to restart the safe therapy with limited number of most efficient primary ATT drugs. Objectives: To study the demographic profile, identify the spectrum of cutaneous eruptions, offending drug and the reinstitution of safe ATT. Materials and Methods: This was a retrospective study with inclusion of the indoor patients with cutaneous adverse drug reaction secondary to ATT. Hospital records were analyzed regarding demographic characteristics, type of TB, ATT regimen, pattern of drug rash, offending drugs, laboratory parameters, and reinstitution of ATT after re-challenge. Results: All the cases (40 patients) were reported in adults with male to female ratio of 1:1.2 and mean age of 50 years. Pulmonary TB was the most common type of TB observed in 24 (60%) patients followed by extra-pulmonary in 16 (40%) patients. Maculopapular rash was the most common (42.5%) type of cutaneous eruptions and ethambutol, the most common (45%) offending drug followed by other first line anti-tubercular drugs. Ten (25%) patients developed multiple drug hypersensitivity on re-challenging. Multiple drug hypersensitivity was seen in 10 (25%) patients. Conclusion: Drug reaction to ATT is like a double-edged sword as stopping ATT and starting treatment of reaction with systemic steroids can further aggravate the condition with increased risk of disseminated and multidrug resistant tuberculosis. Re-challenge with ATT not only find out the culprit drug but also helps to restart a safer alternate ATT regimen. Limitations: Small sample size, lack of proper hospital records due to which some patients were missed and the fact that re-challenge was not performred in mild lichenoid type rash.
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Real-life efficacy and safety of biosimilar adalimumab (ZRC-3197) in patients with plaque psoriasis: A tertiary care center experience p. 182
Ajay Chopra, Debdeep Mitra, Reetu Agarwal, Neerja Saraswat, Pooja Chemburkar, Loknandini Sharma
Background: Adalimumab is proven to be safe and effective in treating plaque psoriasis. A biosimilar adalimumab (ZRC-3197; Exemptia™) - approved by Indian Regulators in 2014 - is a 'fingerprint match' of the reference adalimumab in terms of purity, potency, safety, and clinical efficacy. While reference adalimumab remains unavailable, this biosimilar adalimumab (bADA) serves as an accessible, cost-effective option for Indian patients. This is a first-hand, prospective, real-life data on the clinical use of bADA in Indian patients with plaque psoriasis. Materials and Methods: Patients with moderate-to-severe plaque psoriasis were prospectively treated with bADA therapy for 16 weeks-80 mg subcutaneously initially, followed by 40 mg every other week from week 1 in real-life setting. Psoriasis Area and Severity Index (PASI) responses, Dermatology Life Quality Index (DLQI) outcomes, and Physician's Global Assessment (PGA) for psoriasis were analyzed. Safety and tolerability evaluations included reported adverse events. Results: A total of 29 patients (15 males) with median age of 38 (25–56) years were included. After 16 weeks of bADA treatment, 93% patients achieved ≥75% reduction in their baseline PASI scores including PASI75, PASI90, and PASI100 responses in 24%, 14%, and 55% patients, respectively. About 52% patients had a DLQI score of 0/1 and 93% patients had a PGA score of 'clear or minimal' at 16 weeks. Treatment was well tolerated with no severe or serious adverse reactions requiring therapy discontinuation. Conclusions: This report serves as a real-life evidence for the efficacy and tolerability of biosimilar adalimumab administered for 16 weeks in patients with plaque psoriasis.
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The impact of onychopathies on quality of life: A hospital-based, cross-sectional study p. 187
Hera Tabassum, Mohammad Adil, Syed S Amin, Mohd Mohtashim, Roopal Bansal, Divya Agrawal
Background: Onychopathies or nail disorders are associated with social stigma and causes limitation of daily activities by hampering the function of both fingers and toes. Aim: To evaluate the impact of onychopathies on quality of life (QoL) and compare the severity of impact on QoL in various nail disorders. Materials and Methods: A hospital-based cross-sectional study consisting of 540 patients with onychopathies was conducted in the dermatology outpatient department. Patients were requested to complete a nail-specific QoL questionnaire consisting of 24 and 16 questions, respectively, for fingernails (group F) and toenails (group T) with five possible responses to each question. A score of 1-5 was given to each response. Statistical analysis was done to compare the impact of QoL on the different types of onychopathies. Results: We found that onychopathies have a significant impact on QoL. QoL was significantly more affected when multiple nails were involved (P = 0.020 for group F and P = 0.001 for group T). QoL impact was statistically more significant in women (P = 0.038 for group F andP < 0.001 for group T) and in younger people aged <20 years in group F and 20-39 years in group T (P < 0.001 for both groups F and T). Patients with onychomycosis, structural nail defects, and psoriasis had a more significant impact than other diseases (P < 0.001 for both groups F and T). Conclusion: Onychopathies have a significant adverse effect on QoL because of their serious physical, psychological and social impact. Hence, clinicians should treat the nail disorders with utmost seriousness.
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Nail changes in leprosy: An observational study of 125 patients p. 195
Chetan D Rajput, Balkrishna P Nikam, Sanjay B Gore, Shailesh S Malani
Introduction: Leprosy is a disease primarily affecting skin and nerve. Nail involvement, although indirect, is observed in several patients. This is a study to determine the pattern of nail changes in leprosy. Methods: It was an observational study involving 125 patients. Apart from cutaneous and neurological examination, nails were examined. Diagnosis was confirmed by previous records in already diagnosed cases, while by slit skin smear and histopathologically in new cases. Patients were grouped as per Ridley-Jopling classification and further subdivided as per age, sex, and duration and reaction status. Nail changes in these groups were summarized and compared. Results: Overall prevalence of nail changes was 80% with 66.6% in TT patients, 79.4% in BT patients 50% in BB patients, 83.7% in BL patients and 84.3% in LL patients. Longitudinal melanonychia and longitudinal ridges were frequent finger nail changes with longitudinal melanonychia being more common among tuberculoid pole and longitudinal ridges among lepromatous pole. Brachyonychia, subungual hyperkeratosis and brown black pigmentation were frequent finger nail changes, with onychorrhexis being commonest among TT patients, subungual hyperkeratosis among BT patients, while brachyonychia among BL and LL patients. Anonychia and rudimentary nails were not found in tuberculoid pole. Beau's lines, terry nails, pterygium, pincer nail, and onychorrhexis were significantly more frequent in ENL patients. Onychomadesis, which is not reported yet in leprosy, was found in one patient after severe ENL. Conclusion: Various changes in leprosy are due to multiple causes like neuropathic, traumatic, vascular, osseous, infections and drugs reflecting extensive systemic morbidity caused by Mycobacterium leprae.
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Dermoscopic characterization of dermatophytosis: A preliminary observation p. 202
Balachandra S Ankad, Samipa S Mukherjee, Balakrishna P Nikam, Apoorva S Reshme, Punit S Sakhare, Prabhu H Mural
Introduction: Dermatophytosis has become resistant and relapsing infection in India. Diagnosis of dermatophytosis is easy, however, poses diagnostic challenge in partial treatment, steroid abuse. Dermoscopy is noninvasive tool for diagnosis of many infestations and infections. Dermoscopy in dermatophytosis is not well documented. We evaluated dermatoscopic patterns to correlate with histopathological changes. Materials and Methods: Study was conducted in tertiary hospital after obtaining ethical clearance and informed consent. DermLite 3 dermoscope was used to examine the lesions. Polarized and nonpolarized modes were used and ultrasound gel was utilized. Potassium hydroxide mount and skin biopsy was done to confirm the diagnosis. Results: About 30 patients with 16 males and 14 females were present. Median duration was 3.5 months and median age was 30 years. The most common site was waist and crural area affecting 20 (66.66%). Dermoscopy revealed brown to black dots, globules, and white scales in all patients (100.0%). Lesions of shorter duration (26.66%) demonstrated red dots, dotted vessels, reddish-brown dots, and globules, and brown to black dots and globules were noted in lesions of longer duration (73.33%). Hair changes were noted in five (16.66%) patients. Conclusion: Dermoscopy showed particular patterns in dermatophytosis. Patterns were consistent irrespective of age, sex, and site of involvement. Presence of reddish-brown and black globules with white scales was found to be the most characteristic dermoscopic feature.
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Study of clinical profile of patients presenting with topical steroid-induced facial dermatosis to a tertiary care hospital p. 208
Sonal Jain, Liza Mohapatra, Prasenjeet Mohanty, Swapna Jena, Binodini Behera
Background: Topical corticosteroids (TCs) are widely used for various indications in dermatology. However, these can cause a plethora of symptoms if overused or abused. Topical steroid damaged face is a relatively new entity which was described in 2008. TC abuse cause a myriad of side effects viz, erythema, telangiectasia, acne, acneiform eruption, hyper/hypopigmentation, rosacea, and photosensitivity when used inappropriately. Aim: The aim of the study was to ascertain the prevalence, demographics, and clinical presentations of TC abuse on faceamong our population. Materials and Methods: This was a cross-sectional study performed at dermatology department of a tertiary care teaching hospitallocated in eastern India for 1 year. All patients with facial dermatoses attending the outpatient department were asked about use of TC in recent past and those with positive history were included. A detailed clinical evaluation was undertaken and various demographic and clinical data were recorded. Results: A total of 316 patients (53 males, 263 females) presented with topical steroid-induced facial dermatoses during the entire study period. Majority of them used these agents on suggestion of close friends and relatives, pharmacists, television commercials, and doctors. Mometasone in the form “No-Scar” preparation was the most commonly abused topical steroid in our study. The most common side effects encountered were steroid-induced acne (45.2%) or flare of pre-existing acne followed by erythema and telangiectasia (21.2%), hypertrichosis (6.6%), rosacea (2.2%), and atrophy (1.5%).The most common reason for abusing TC was to get a fairer skin tone. Conclusion: Our study reports the clinical patterns of TC abused facial dermatoses.The fantasy to get a fairer skin among the people of our country has led to the abuse of topical corticosteroids. We conducted this study to create awareness among these patients about the dreadful effects of steroid misuse.
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Angiokeratoma corporis diffusum: An uncommon case with suspected anderson fabry disease p. 212
Priyanka Vadher, Pooja Agarwal, Amit Mistry, Krishna Gajjar, Nalini Bansal, Sabha Neazee
Angiokeratomas are variable sized hyperkeratotic vascular papules that are characterized histologically by superficial dilated capillaries in papillary dermis with epidermal proliferation. They can occur as a single lesion to a generalized form (angiokeratoma corporis diffusum). Angiokeratoma corporis diffusum though initially synonymous with Anderson Fabry disease, is now known to occur in a variety of lysosomal enzyme deficiencies. We report a case of 22 year old male with angiokeratoma corporis diffusum associated with acroparesthesias, febrile episodes, sensorineural hearing loss and renal involvement. Histopathological evaluation showed characteristic ectatic blood vessels with vacuolated endothelial cells in papillary dermis. Based on the clinical evaluation and available investigations, we suspected him to be having to Anderson fabry disease. Resource constraints limited our ability to confirm our diagnosis with enzyme assay and electron microscopy. We report this unusual case in desire of re emphasizing the importance of clinical evaluation for reaching a diagnosis in a resource poor setting.
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Parameatal median raphe cyst: A case report of a midline developmental defect of true urogenital origin p. 216
Aseem Sharma, Sandip Agrawal, Tejas Vishwanath, Smita Ghate, Rachita Dhurat, Kiran Chahal
Median raphe cyst (MRC) is an uncommon, asymptomatic benign lesion, that may present anywhere on the midline ridge between the external urethral meatus and the anus. Although they are developmental in origin, they often present in the postpubertal age, aggravated by trauma, and are frequently infected secondarily. MRCs are often misdiagnosed as epidermal cysts, steatocystoma multiplex, and eccrine cystadenomas. They are underrecognized and less than ten case reports exist from the Indian subcontinent. We, herein report a male with an immunohistochemically proven parameatal MRC.
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Hemophagocytic lymphohistiocytosis complicating methotrexate toxicity p. 219
VT Anjali, Reena Rai, G Uma Maheswari, Prasanna N Kumar
Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal disease caused by dysregulated activation of macrophages against one's blood cells. Major pathologic feature of HLH is hemophagocytosis. We present a case of HLH complicating methotrexate toxicity in a 65-year-old psoriatic patient with history of renal disease. Diagnosis of HLH was established as he fulfilled five out of eight HLH diagnostic criteria. This case report is presented to enlighten clinicians about the clinical entity of HLH and to suspect and recognize this rare and generally fatal disease at the earliest.
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Pyoderma gangrenosum over hypertrophic scar: Report of a rare presentation p. 222
Arpita N Rout, Kananbala Sahu, Chandra S Sirka
Pyoderma gangrenosum (PG) is a chronic neutrophilic dermatoses characterised by large ulcer healing with cribriform scar. PG can rarely occur over the healed scar. Its diagnosis depends on clinical morphology and exclusion of other diseases. We report a case of large pyoderma gangrenosum ulcer on a hypertrophic scar since 1 year. Biopsy from ulcer edge was suggestive of PG and hypertrophic scar. The hypertrophic scar had been formed by healing of a large ulcer 2 years back. The ulcer healed to two-third size over next three months with monthly dexamethasone pulse, daily oral steroid and dapsone. This case was unique since the PG ulcer had occurred over a hypertrophic scar. Such a presentation in PG is rare and physicians should be aware of such occurrence of PG.
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Cutaneous angiomyolipoma of the ear: A rare diagnostic challenge p. 226
Karin Milleni Araujo, Rodrigo Denadai, Rafael Denadai
Cutaneous angiomyolipoma is an extremally rare mesenchymal tumor, distinct from its renal counterpart. We describe two patients with cutaneous angiomyolipoma of the earlobe, all of which were clinically misdiagnosed and mistreated as epidermoid cysts, to highlight the need to consider a broad spectrum of differential diagnoses when evaluating any nodular or cystic tumor of the ear. We also provide a comprehensive literature review about this cutaneous entity.
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Simultaneous bullous pemphigoid and vitiligo associated with adalimumab therapy in a patient with psoriasis vulgaris p. 229
Andrés Tirado-Sánchez, Alexandro Bonifaz
Antitumor necrosis factors (TNFs) agents are increasingly being used for the effective treatment of diverse diseases. Due to its extensive use and longer duartion of treatment, there are a growing number of reports of the development of autoimmune conditions such as systemic lupus erythematosus, bullous pemphigoid (BP), and vitiligo associated with the use of anti-TNF agents. We describe a patient who developed BP as well as vitiligo after receiving treatment with adalimumab for plaque psoriasis. To our knowledge, this is the first case of simultaneous presentation of two diseases related to the use of adalimumab, and this highlights the importance of monitoring for more than one autoimmune event during TNF inhibition treatment.
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Annular pattern of pustular vasculitis: A case report of unusual morphological presentation p. 232
Kananbala Sahu, Chandra Sekhar Sirka, Swetalina Pradhan, Arpita Nibedita Rout, Subhasini Nayak
Pustular cutaneous vasculitis is a rare entity. Only handful cases are reported from all over the world. They typically present with painful pustules mainly over dorsum of hands and rarely on lower legs. We report a 50-year female who presented with painful pustules arranged in annular pattern predominantly distributed over lower limbs. Laboratory investigation ruled out any systemic associations. Histopathology was suggestive of pustular vasculitis. Final diagnosis of idiopathic pustular vasculitis was made. The patient was successfully treated with oral prednisolone and dapsone without any recurrence on follow up. It is the first report of annular morphological presentation of pustular vasculitis.
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Atypical cutaneous presentation of chronic tophaceous gout: A case report p. 235
Swetalina Pradhan, Ruchi Sinha, Preeti Sharma, Upasna Sinha
Gout is a metabolic disease that occurs either because of increased uric acid production or decreased uric acid secretion. It most commonly affects middle-aged to elderly men and postmenopausal women. Chronic tophaceous gout frequently occurs after 10 years or more of recurrent polyarticular gout. Gouty tophi are deposition of monosodium urate (MSU) crystals in and around joints as well as soft tissues. We present a case of chronic tophaceous gout in a 21-year-old male, which occurred after 4 years of onset of gouty arthritis. The patient presented with tophaceous gout in four forms, that is, periarticular subcutaneous tophi, disseminated intradermal tophi, ulcerative form, and miliarial tophi along with multiple sinuses discharging chalky white material. The case was diagnosed as chronic tophaceous gout on the basis of raised serum uric acid, imprint smear showing needle-shaped crystals and negatively birefringent crystals on polarized microscopy. The case is interesting for varied morphological forms of tophaceous gout in a patient at an early age and shorter interval between onset of gouty arthritis and tophaceous gout.
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Washout period for pregnancy post isotretinoin therapy p. 239
Hina Jajoria, Venkataram Mysore
Introduction and Background: Isotretinoin is an oral medication used for the treatment of severe acne unresponsive to other medications. This drug is teratogenic and should be prescribed with appropriate caution in selected group of patients. The washout period for pregnancy post isotrenoin therapy has always been a topic of controversy. Several guidelines have recommended a wash out period of one month if pregnancy is planned in a patient being administered with the drug. Objective: This article discusses the available evidence for different recommended wash out periods and addresses important clinical questions that arise. Methods: Pubmed research was carried out to collect relevant data using the keywords isotretinoin, pregnancy, contraception, pharmacokinetics and guidelines. Conclusion: Our research based on the published data concludes that a wash out period of 35 days post isotretinoin therapy is adequate in routine clinical practice.
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Dyschromatosis universalis hereditaria with hypospadias: A rare association p. 243
Chandra Sekhar Sirka, Kananbala Sahu, Arpita Nibedita Rout
Dyschromatosis universalis hereditaria (DUH) is a rare genodermatosis, which presents as hyper- and hypopigmented macules all over the body.Although a benign condition, rarely DUH is associated with abnormalities of dermal connective tissue, nerve, and systemic conditions. We report a case of DUH associated hypospadias and complicated with hydronephrosis that has not been described earlier.
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Bardet–Biedl syndrome with café-au-lait macule: Association or coincidence? p. 246
Suyash S Tomar, Bhagyashree B Supekar, Apoorva Chopkar, Jayesh Mukhi, RP Singh
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Tattoo for camouflage: A new cause of tattoo regret p. 250
Anuja Yadav, Pravesh Yadav, Jyoti Yadav, Ram Chander
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Trichilemmoma coexisting with sebaceous nevus p. 253
Angoori G Rao, Vangali S Reddy, M Tejal, M Divya
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Glycopyrrolate-induced black hairy tongue p. 256
Neel Prabha, Ripu Daman Arora, Nikhil Singh, Nitin M Nagarkar
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Rubinstein-Taybi syndrome: A rare case report Highly accessed article p. 258
Suyash S Tomar, Bhagyashree B Supekar, Jayesh Mukhi, Rajesh Pratap Singh
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Nivolumab (PD-1 Inhibitor) induced exacerbation of psoriasis p. 261
Anju George, Renu George
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A case of familial trichomegaly with synophrys in association with loose anagen syndrome p. 263
Sinu Rose Mathachan, Surabhi Sinha, Kabir Sardana, Purnima Malhotra
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8-year-old girl with polymorphic scars on the face p. 266
Garima Dabas, Ankur Guliani, Divya Aggarwal, Rahul Mahajan
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An unusual presentation of post kala-azar dermal leishmaniasis p. 269
Sucheta Pathania, Pramila Kumari, Swastika Suvirya, Jaya Chakravarty
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Epidermolytic nevus: An instance of mosaic epidermolytic ichthyosis p. 272
Keshavmurthy A Adya, Arun C Inamadar, Ajit B Janagond, Aparna Palit
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Congenital insensitivity to pain with anhidrosis: A rare entity p. 274
Priya Rajbansh, Mamta Yadav, Piyush Kumar, Anupam Das
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Necrolytic acral erythema in seronegative hepatitis C patient with vitamin B12 deficiency p. 278
Richa Kumar, Sandeep Arora, Eeshaan Ranjan, Niyor Das
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Bullous striae distensae with prolonged steroid use: An unusual clinical presentation p. 280
Sadia Masood, Palwasha Jalil, Shaheen Naveed, Samra Kanwal
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Preventing cross-infection during polarized dermoscopy using hand held dermoscopes p. 282
Feroze Kaliyadan, Puravoor Jayasree
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Erythematous nodular scalp swellings showing central ulceration and hemorrhagic crusting in an 83-year-old man p. 284
Ashish Jagati, Raju G Chaudhary, Santoshdev P Rathod, Arwinder Kaur Brar
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Skin-Coloured papules on elbows and knees with foamy cells p. 286
Ushma Kantamuneni, Manasa Narayan Kayarkatte, Venkatram Mysore
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The curious case of an elusive solitary plaque p. 288
Saloni Katoch, Taranga N Barua, Khagendra N Barua
A 60-year-old male patient presented with a solitary pink plaque over the inner aspect of the left forearm of 4 years duration. The lesion was persistent and unresponsive to treatment. A skin biopsy was done with differential diagnosis of lupus vulgaris, tuberculoid leprosy, and granuloma annulare. Histopathology revealed features suggestive of morphea and the patient was treated accordingly. Despite treatment, the lesion continued to grow in size and a repeat biopsy was done as clinical doubt regarding the diagnosis persisted. Dermoscopy, KOH wet mount, and histopathology revealed characteristic features that clinched the diagnosis and aided in correct management of the patient with complete clearance of lesion after 4 months of therapy.
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Cluster of flowers – The unseen of syphilis p. 291
PK Ashwini, Anu T George, Jayadev Betkerur
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Extensive becker's melanosis in a checkerboard mosaic pattern p. 294
Rini Makhija, Lalit K Gupta, Ashok K Khare, Asit Mittal
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Mucoscopy of discoid lupus erythematosus on lower lip p. 296
Manisha Chandela, Rachita Misri, Deepak Jakhar
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Dermoscopy of localized darier's disease in fitzpatrick type IV skin p. 298
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit
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