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   Table of Contents - Current issue
July-August 2019
Volume 10 | Issue 4
Page Nos. 365-501

Online since Friday, June 28, 2019

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Hereditary palmoplantar keratoderma: A practical approach to the diagnosis Highly accessed article p. 365
Tanvi Dev, Vikram K Mahajan, Gomathy Sethuraman
The ridged skin of the palms and soles has several unique features: (i) presence of dermatoglyphics created by alternating ridges and grooves forming a unique pattern, (ii) presence of the highest density of eccrine sweat glands and absence of pilosebaceous units, and (iii) differential expression of keratins compared to the glabrous skin. These features explain the preferential localization of palmoplantar keratoderma (PPK) and several of its characteristic clinical features. PPK develops as a compensatory hyperproliferation of the epidermis and excessive production of stratum corneum in response to altered cornification of the palmoplantar skin due to mutations in the genes encoding several of the proteins involved in it. PPK can manifest as diffuse, focal, striate, or punctate forms per se or as a feature of several dermatological or systemic diseases. There is a wide genetic and phenotypic heterogeneity in hereditary PPK, due to which reaching an accurate diagnosis only on the basis of clinical features may be sometimes challenging for the clinicians in the absence of molecular studies. Nevertheless, recognizing the clinical patterns of keratoderma, extent of involvement, degree of mutilation, and associated appendageal and systemic involvement may help in delineating different forms. Molecular studies, despite high cost, are imperative for accurate classification, recognizing clinical patterns in resource poor settings is important for appropriate diagnosis, genetic counseling, and management. This review intends to develop a practical approach for clinical diagnosis of different types of hereditary PPK with reasonable accuracy.
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Striae distensae treatment review and update Highly accessed article p. 380
Archana J Lokhande, Venkataram Mysore
Striae distansae (SD) or stretch marks are very common, asymptomatic, skin condition frequently seen among females between 5 to 50 years of ages. It often causes cosmetic morbidity and psychological distress, particularly in women and in certain professions where physical appearances have significant importance. Of late, with the increasing emphasis on cosmetic management and awareness, patients approach dermatologists for stretch marks treatment. However, despite several advances, no fully effective treatment has emerged. Unfortunately, there is paucity of the strong evidence in the literature for the effective treatment of striae. A literature search using the terms 'striae distansae (SD or stretch marks' was carried out in the PubMed, Google Scholar and Medline databases. Only articles related to the treatment were considered and analysed for their data. Commonly cited treatments include topical treatments like tretinoin, glycolic acid, ascorbic acid and various lasers including (like) carbon dioxide, Er:YAG, diode, Q-switched Nd:YAG, pulse dye and excimer laser. Other devices like radiofrequency, phototherapy and therapies like platelet rich plasma, chemical peeling, microdermabrasion, needling, carboxytherapy and galvanopuncture have also been used with variable success. This article reviews all currently accepted modalities and their effectiveness in the treatment of stretch marks.
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Common contact allergens in patients with chronic vesicular dermatitis of palms and soles: A retrospective study p. 396
Sanjeev Gupta, Sahil Pruthi, Ajay Kumar, Aneet Mahendra
Background: Chronic and recurrent vesiculation over the palms and soles is termed chronic vesicular dermatitis. Its etiology is multifactorial and contact allergy plays an important role. Aim: The aim of the study is to evaluate the clinical relevance of patch test reactivity to common contact allergens in chronic palmoplantar vesicular dermatitis. Materials and Methods: An observational study was conducted enrolling 152 patients of chronic palmoplantar vesicular dermatitis. Patch testing was carried out with the Indian Standard Battery and also with the materials used by patients. Statistical analysis was carried out using SPSS software. Results: Among 152 patients, 91 were female and 61 male. The peak incidence was in the 14–24 years age group. Their occupations included housewives 48, laborers 26, factory workers 16, farm workers 14, and shopkeepers 12. Patch tests were positive in 79 (52%) patients, including 43 (28.3%) female and 36 (23.7%) male. Patch test reactivity was observed with nickel in 25 (16.4%); potassium dichromate in 21 (13.8%); fragrance mix in 17 (11.2%); p-phenylenediamine in 14 (9.2%); black rubber in 10 (6.6%); mercaptobenzothiazole in 8 (5.3%); and parthenium in 8 (5.3%) patients. Clinical relevance of positive patch tests was determined in 47 (59.5%) patients. Conclusions: Though patch test reactivity was higher in females as compared with males, the difference was not statistically significant. Clinical relevance of positive patch tests was established with nickel in 9 (19.1%) patients; antigens associated with rubber including black rubber, mercaptobenzothiazole, and thiuram mix in 7 (14.9%); potassium dichromate in 7 (14.9%); p-phenylenediamine in 6 (12.8%); and parthenium in 4 (8.5%) patients.
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Assessment of the Possible Role of FOXP3 Gene (rs3761548) Polymorphism in Psoriasis Vulgaris Susceptibility and Pathogenesis: Egyptian Study p. 401
Magdy Abdelmageed Elsohafy, Ashraf Antar Elghzaly, Hebatallah Mansour Abdelsalam, Mohammad A Gaballah
Background: Psoriasis is an autoimmune-related chronic inflammatory skin disorder. Psoriasis vulgaris (PV) is the most common form of psoriasis. T regulatory cells (Tregs) are typically considered inhibitors of autoimmune responses. FOXP3 is a master control transcription factor for development and function of Tregs. FOXP3 gene polymorphism changes FOXP3 protein function and quantity leading to Tregs dysfunction that subsequently may be related to PV pathogenesis. Objective: The objective of the present study was to evaluate the possible role of FOXP3 gene (rs3761548) polymorphism in PV pathogenesis. Materials and Methods: One hundred sixty subjects were included in the present study (80 PV patients and 80 well-matched healthy controls). All participants were evaluated by detailed history, general examination, dermatological examination, and psoriasis area and severity index (PASI) score. The detection of FOXP3 gene (rs3761548) polymorphism in patients and controls by PCR-restriction fragment length polymorphism technique was done. Results: There was statistically significant increase in CC genotype and C allele in patients compared to controls, whereas there were non-significant differences in AA and AC genotypes. However, there were non-significant associations between genotype distribution and each of age, sex, family history, PASI score, hair affection, nail affection, hypertension, diabetes mellitus, and body mass index. Conclusion: FOXP3 gene (rs3761548) polymorphism may increase susceptibility of PV and share in its pathogenesis as it leads to changes in FOXP3 protein function and quantity that subsequently affect T-regs functions. Further investigations for the role of other FOXP3 genes polymorphisms in psoriasis pathogenesis and their effects on the treatment response in psoriasis patients are strongly recommended.
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Clinicoepidemiologic profile and the cutaneous and nasal colonization with methicillin-resistant Staphylococcus aureus in children with atopic dermatitis from North India p. 406
Vanya Narayan, Rashmi Sarkar, Krishna Deb Barman, S Krishna Prakash
Background: There is a paucity of literature about the atypical clinical manifestations in children with atopic dermatitis (AD) in Asian setting, and colonization with methicillin-resistant Staphylococcus aureus (MRSA), and its association with disease severity, if any. Objective: To elucidate atypical clinical patterns of AD in children and to determine the MRSA isolation and its association with disease severity. Methods: We studied 55 pediatric patients from 2 months to 10 years of age, of either sex, diagnosed with AD based on the diagnostic criteria of Hanifin and Rajka. History, clinical examination (including atypical features), and severity score using SCORing Atopic Dermatitis (SCORAD) severity index were recorded. Swabs from the cutaneous lesion and anterior nares were collected from each case and processed. Statistical analysis was done by SPSS (V 17). Observations and Results: Atypical clinical features were seen in 52.7% of cases. Retroauricular fissures (among atypical features), oozing, crusting, darkening, early age at onset, and nipple eczema were found to be significantly associated with disease severity (P < 0.05). The majority of the cases (56.4%) fell in the moderate disease severity (mean SCORAD 32.02). MRSA showed an isolation frequency of 7.27% from the skin swabs and 10.90% from the nares. No significant association was found between Staphylococcus aureus isolates (including MRSA) and disease severity in our study. A high degree of fluoroquinolone resistance was noted in MRSA isolates. Limitation: Further characterization of S. aureus by superantigen profiling was not done. Conclusion: Patients with AD need to be evaluated for atypical features which may serve as markers of severe disease.
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An observational cross-sectional study of varied clinical manifestations of connective tissue disorders and their association with antinuclear antibodies in a tertiary care center p. 413
Rana Abdul Kadiru, Spandana P Hegde, Manjunath M Shenoy
Context: Connective tissue disorders (CTD) occur in 3–5% of the population. The advent of antibodies to extractable nuclear antigens (ENA) has become a reliable predictor to establish the diagnosis of CTD, subclassify patients into prognostic groups, and monitor disease activity. Aims: The aim of this study was to (a) study the frequency of cutaneous manifestations, systemic manifestations, and anti-ENA antibodies in CTD; (b) determine the association between systemic manifestations and ENAs; and (c) determine the association between cutaneous and systemic manifestations of CTD. Subjects and Materials: An observational cross- sectional study was conducted on 50 patients diagnosed to have CTD. The clinical profile and antibodies to ENA (ANA Profile) reports were retrieved and studied. Results: The major dermatological manifestations were skin tightness (36%), salt and pepper pigmentation (30%), Raynaud's phenomenon (28%), and malar rash (28%). The common antibodies seen were anti SS-A (36%), anti-UI-ribonucleoprotein (U1-RNP) (34%), anti-dsDNA (32%), and anti-Sm (24%). Patients with anti-Sm and anti-dsDNA antibodies had increased frequency of renal manifestations. A strong association with significant P values was seen between neurological manifestations and anti-Sm antibody, and cardiovascular manifestations and anti-RNP antibody. An association between gastrointestinal manifestations and malar rash as well as neurological manifestations and photosensitivity was also seen. Conclusions: ENA panel predicts systemic involvement, thus helping in the multidisciplinary management. Cutaneous manifestations of CTD can be an early predictor in giving a clue to impending systemic manifestations.
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Effectiveness of dual sequential wavelength laser in the treatment of portwine stains – A retrospective study p. 418
Mohan Kumar Periyasamy, C Shanmuga Sekar, Reena Rai
Background: Port Wine Stain (PWS) is only partially and superficially treated with the Pulsed dye laser (PDL) because of its limited depth of penetration. The 1064-nm long pulsed Nd:YAG laser has greater depth of penetration and is used to treat deeper vessels. The dual sequential wavelength laser (DSWL) which combines PDL/Nd:YAG (595/1064 nm) can be more effective for the treatment of deeper, nodular portwine stains due to its synergistic effect. The purpose of this study is to evaluate the efficacy and safety of DSWL in the treatment of portwine stains after five treatment sessions. Materials and Methods: A total of 11 patients with PWS lesions on the head and neck, who were treated with DSWL for at least five sittings at monthly interval were included in this study. The assessment of the therapeutic response and grading of improvement was done with a scale of 0 to 4 by comparing the photographs taken before treatment and after 5 sittings of laser treatment. Results: Out of the 11 patients, 5 patients (45.45%) had more than 70% improvement. Six out of eleven patients (54.54%) had 40 to 70% improvement at the end of five sittings with no adverse effects including purpura. Conclusion: Dual Sequential Wavelength Laser is a good modality of treatment for portwine stains. It has enhanced penetration and effective clearance of thicker, nodular, recalcitrant lesions of PWS. DSWL is safe and efficacious and it can be recommended as a therapeutic modality for portwine stains.
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Tinea pseudoimbricata as a unique manifestation of steroid abuse: A clinico-mycological and dermoscopic study from a tertiary care hospital p. 422
Archana Singal, Deepak Jakhar, Ishmeet Kaur, Deepika Pandhi, Shukla Das
Background: Tinea pseudoimbricata, characterized by concentric scaly rings simulating Tinea imbricata is caused by dermatophytes other than Trichophyton concentricum. It is reported to occur in patients with steroid abuse and in immunocompromised individuals. Aim: To study the clinico-mycological profile and dermoscopic features of T. pseudoimbricata in immunocompetent patients. Methods: We have evaluated 14 consecutive, clinically diagnosed patients of T. pseudoimbricata with positive 10% potassium hydroxide (KOH) examination and culture, seen over a period of 6 months. Dermoscopy was performed in all patients. The demographic, clinical, and mycological features of each patient were recorded on a predesigned proforma. Results: There were seven male and seven female patients with a mean age of 27.6 years and a mean disease duration of 3.8 months. All patients gave a history of application of potent or super-potent topical steroid with or without oral/injectable steroid for varying duration. Culture isolates were Trichophyton mentagrophytes complex and Trichophyton rubrum in 11 and 3 patients, respectively. Dermoscopic analysis showed features of steroid abuse in majority of the patients. Limitation: A small sample size was the limitation of our study. Conclusion: T. pseudoimbricata is a special subset of Tinea incognito caused by injudicious and inappropriate use of topical steroid. The typical appearance should alert the dermatologists regarding the possible abuse of steroids. Most common species isolated on culture was T. mentagrophytes complex.
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A descriptive study to analyze chemotherapy-induced hair loss and its psychosocial impact in adults: Our experience from a tertiary care hospital p. 426
Neerja Saraswat, Ajay Chopra, Aradhana Sood, Parul Kamboj, Sushil Kumar
Background: Hair loss is one of the most commonly reported and psychologically distressing adverse effects of chemotherapeutic agents. Studies on its impact on psychosocial aspect of cancer patients are lacking at present. Objective: To study the chemotherapeutic agents causing hair loss and its psychosocial implications in adults. Materials and Methods: Observational study was done for a period of 1 year, wherein all cancer patients, more than 18 years of age who developed hair loss while on chemotherapy were assessed for type of malignancy, details of chemotherapy protocol, their knowledge about chemotherapeutic agents induced hair loss, and its impact on their social life and patterns of adjustment to deal with it. A prevalidated closed-ended questionnaire was used as a data collection tool. Results: Out of 179 patients, 96 (53.6%) were males as against 80 (44.6%) females, and 49 (27.3%) patients were between 18 and 30 years of age. Carcinoma lung was the most common malignancy seen in 46 (25.6%) patients followed by rectosigmoid carcinoma in 41 (22.9%) patients. Combination of cyclophosphamide and doxorubicin was the most common combination resulting in hair loss in 49 (27.3%) cancer patients. A total of 101 (56.4%) patients felt that hair loss was the worst side effect of chemotherapy, while 29 (16.2%) had to continue because it was life-saving. A total of 129 (72%) patients said hair loss is affecting their social life; 37 (20.6%) patients were using hair accessories while 69 (38.5%) did not even attempt to hide hair loss as they were too occupied with fear of disease. Conclusion: Chemotherapy-induced hair loss is a common adverse effect in cancer patients undergoing treatment. A thorough counseling about it and methods to deal with it should be a part of management of the patients.
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Quantitative and qualitative analysis of mast cells in oral lichen planus and its effect on basement membrane using special stains p. 431
Treville Pereira, J Aswathy, Subraj Shetty, Avinash Tamgadge, Sandhya Tamgadge, Swati Gotmare
Background: Oral lichen planus (OLP) is characterized histologically by epithelial basal cell destruction and a dense subepithelial lymphocytic infiltrate. Mast cells (MCs) play a role in the pathogenesis and progression of the disease causing changes in the basement membrane (BM). BM is seen as continuous or fragmented, distinct or indistinct, and afibrillar or fibrillar extensions. Aims and Objectives: This study was done to demonstrate the BM using acriflavine stain in addition to hematoxylin and eosin (H-E) stain. An attempt was also made to study MC using Azure A stain and assess the degree of changes in the thickness of BM associated with degranulated MC in patients with OLP. Materials and Methods: A total of 66 paraffin-embedded tissue sections which included 30 inflamed gingival mucosa (IGM) and 36 OLP were stained with H-E stain, Azure A, and fluorescent periodic acid–acriflavine stain. Results: MC density was higher in OLP when compared with MC in IGM. Degranulated MCs were found in abundance in OLP. Thickness of BM was significantly less in OLP when compared with IGM. Significant fragmentation was seen in OLP when compared with BM of IGM. Conclusion: Degranulated MC in OLP may or may not alter the quality of BM but definitely seems to influence the thickness of the BM both directly and indirectly.
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A survey of treatment practices in management of psoriasis patients among dermatologists of Kerala p. 437
Mohammed Nazeer, Surya Ravindran, Geethu Gangadharan, Sebastian Criton
Introduction: The management of psoriasis is a daily challenge for dermatologists as most patients present with varied morphological presentations and exacerbations at every visit. This exerts a heightened responsibility on the dermatologists to tailor their treatments according to each patient. Aims: This study was conducted to assess the variation in treatment practices in the management of psoriasis patients among dermatologists of Kerala. Materials and Methods: A questionnaire-based survey was conducted among the practicing dermatologists of Kerala, South India. Conclusions: At the end of this questionnaire-based study, we concluded that there is a wide variation in the treatment practices among practicing dermatologists of Kerala. Dermatology Life Quality Index (DLQI) is not assessed by majority of dermatologists while planning treatment. Most dermatologists rely on body surface area while planning treatment due to time constraints and did not perform PASI (Psoriasis Area and Severity Index) or PGA (Physician Global Assessment) scoring. Satisfaction and challenges related to current therapies also impact treatment rates. Our dermatologists adhered to their own individual guidelines while treating and expressed a dire need for a unified guideline.
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Complex cost issues in treating dermatophytoses in India—”It all builds up” p. 441
Shyam B Verma
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A rare case of possible vacuolar degeneration of leprosy in brain with segmental necrotizing granulomatous neuritis and horner's syndrome p. 444
Sukriti Baveja, Sunmeet Sandhu, Deepak Vashisht
Leprosy has a predilection for peripheral nerves, but rarely does it involve the central nervous system (CNS). There is a single study of CNS involvement in leprosy showing vacuolar changes of motor neurons in medulla oblongata and spinal cord in autopsy findings. Besides this, there has been only one case report providing direct histopathological and molecular evidence of CNS involvement by leprosy in a living patient. Segmental necrotizing granulomatous neuritis (SNGN) is a rare condition affecting the peripheral nerves in leprosy usually seen as a complication of tuberculoid (TT) and borderline tuberculoid (BT) leprosy. We report the case of a 23-year-old male patient, a case of Hansen's disease (BT) who developed CNS involvement in the form of partial Horner's syndrome (right) and SNGN while on treatment. Magnetic resonance imaging of the brain revealed T2 hyperintense lesion on the dorsal aspect of left pontomedullary junction, suggestive of vacuolar degeneration of leprosy. Histopathology of greater auricular nerve (right) revealed SNGN.
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Cloves syndrome: A rare disorder of overgrowth with unusual features – An uncommon phenotype? p. 447
Vikram K Mahajan, Mrinal Gupta, Pushpinder Chauhan, Karaninder S Mehta
CLOVES syndrome characterized by Congenital Lipomatous Overgrowth, Vascular malformations, Epidermal nevi, and Skeletal anomalies is a recently described sporadic syndrome from postzygotic activating mutations in PIK3CA. This 3-year-old boy, born to nonconsanguineous and healthy parents, had epidermal verrucous nevus, lower limb length discrepancy and bilateral genuvalgum, anterior abdominal wall lipomatous mass, central beaking of L2 and L3, and fibrous dysplasia of the left frontal bone. Ocular and dental abnormalities (ptosis, esotropia, delayed canine eruption, dental hypoplasia), ipsilateral asymmetrical deformity of skull, and large left cerebral hemisphere with mild ipsilateral ventriculomegaly were peculiar to him denoting an uncommon phenotype. The parents did not consent for magnetic resonance imaging and genetic studies because of financial constraints. The CLOVES syndrome has emerged as an uncommon yet distinct clinical entity with some phenotypic variations. Its diagnosis is usually from cutaneous, truncal, spinal, and foot anomalies in clinical and radioimaging studies. Proteus syndrome remains the major differential.
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Tripe palms and acanthosis Nigricans: A clue for diagnosis of advanced pancreatic adenocarcinoma p. 453
Bhupen Barman, L Purnima Devi, Binod Kumar Thakur, Vandana Raphael
Tripe palms is an unusual cutaneous paraneoplastic syndrome characterized by a curious rugose thickening of the palms with an accentuation of the normal dermatoglyphic ridges and sulci. Tripe palms alone or in combination with acanthosis nigricans is strongly associated with internal malignancy, especially carcinomas of the gastrointestinal tract and lung. Any patient with tripe palms must have a complete cancer workup, as in many of the cases it often precedes the malignancy by many months. We report a rare case of tripe palms with acanthosis nigricans in a 50-year-old man with advanced pancreatic adenocarcinoma. Although relatively rare, an early diagnosis is very important to find out underlying malignancy and to improve the prognosis related to the neoplasia.
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Successful use of oral acyclovir in ophthalmic molluscum contagiosum p. 456
Sharad D Mutalik, Yashashree D Rasal
Molluscum contagiosum is a common tropical contagious viral infection, involving the skin and the mucous membranes. Ophthalmic molluscum contagiosum is a relatively uncommon condition presenting as secondary follicular conjunctivitis or kerato-conjunctivitis and may present with or without obvious dermal skin lesions. Often, unsuspected and misdiagnosed by eye care providers or observed as a concomitant feature by a skin care provider, unilateral conjunctivitis due to molluscum contagiosum remains easily treatable. Clearance of the primary skin lesion leads to rapid and complete resolution of ophthalmic signs. Two cases of ophthalmic molluscum contagiosum treated successfully with oral antiviral drug acyclovir are presented herewith as anecdotal therapeutic evidence.
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Penile horn: A rare presentation of pseudoepitheliomatous, keratotic, and micaceous balanitis successfully treated with oral acitretin p. 460
Chandra Sekhar Sirka, Kananbala Sahu, Swetalina Pradhan, Subhasini Naik
Glans penis is an unusual site for horn. Only few cases are reported worldwide in English literature. Pseudoepitheliomatous, keratotic, and micaceous balanitis (PKMB) is a pyodermatitis with pseudoepitheliomatous response to chronic inflammation or infection. Rarely it can develop a horn. There is one case report of PKMB presenting as penile horn and one case with nail-like presentation in the literature. Mode of treatment of PKMB with horn ranged from topical 5-fluorouracil, electrosurgery, and cryosurgery to excision. Use of oral acitretin in PKMB or penile horn is unknown. We are reporting a 60-year-old circumcised male who presented with a penile horn. Histology was suggestive of PKMB. Treatment with topical 5-flurouracil did not work. He was successfully treated with oral acitretin.
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Cutaneous epithelioid angiomatous nodule of breast p. 463
Swagatika Samal, Das Birendra Monohar, Amit Kumar Adhya, Mithilesh Sinha, Suvradeep Mitra
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Eosinophilic cellulitis successfully treated with colchicine p. 467
Murat Ozturk, Egemen Ucan, Ibrahim Ibiloglu
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Koebner phenomenon in classic juvenile onset pityriasis rubra pilaris p. 469
Reena K Sharma, Mudita Gupta, Anchana Gulati
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Treatment of dark circles with the new 15 mg/ml hyaluronic acid filler with lidocaine p. 471
Madhuri Agarwal
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Photosensitive erythema multiforme and its dramatic response to dapsone and the mechanism therein p. 473
Aastha Gupta, Kabir Sardana, Ram K Gautam
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Tinea lesions confined to tattoo site p. 474
Maitreyee Panda, Nibedita Patro, Chinmoy Raj, Monali Pattnaik
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A case of iatrogenic cushing syndrome secondary to application of topical corticosteroids p. 476
Vidyadhar R Sardesai, Suyog Shashikant Dhamale, Shibhani S Hegde
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Porokeratotic eccrine ostial and dermal duct nevus and porokeratotic eccrine and hair follicle nevus: Is nomenclature “porokeratotic adnexal ostial nevus” more appropriate? p. 478
Bhumika Chowdhary, Anuj Sharma, Vikram K Mahajan
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Topical ciclopirox olamine 1%: Revisiting a unique antifungal p. 481
Sidharth Sonthalia, Mahima Agrawal, VN Sehgal
The injudicious use of antifungals, indiscriminate use of corticosteroids for instant relief, persistence of predisposing factors like sweat retention and uncontrolled diabetes, and emerging resistance to antifungals across the globe have rendered the management of an erstwhile simple infection, the superficial cutaneous mycoses highly complicated and tricky. Ciclopirox is an old yet efficacious, versatile, and safe topical antifungal of the hydroxypyridone family. Despite its numerous beneficial properties over the majority of other topical antifungals, it remains underutilized.
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Intralesional radiofrequency for papular acne scars p. 486
Sarita Sanke, Ram Chander, Sonam Mehra
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SkIndia Quiz 52: A verrucous growth over elbow of a young child Highly accessed article p. 488
Ranjana Beniwal, Asit Mittal, Khushboo Gupta, Manisha Balai
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Split plaque over postauricular area p. 490
Ankur Guliani, T Muhammed Razmi, Keshavamurthy Vinay, Divya Aggarwal
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Macula ceruleae with head louse p. 492
Archana J Lokhande, Rohini Soni, Tapan K Dhali
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A case of peeling skin syndrome p. 494
Renuka Satish Ashtekar, Rakhi Soman, Chandrashekhar Shrihari Purandare
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Munchausen syndrome by proxy p. 496
Anuradha Kakkanatt Babu, Akbar Mohamed, Namitha Das
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Mucoscopy of fordyce's spots on lips p. 498
Deepak Jakhar, Ishmeet Kaur
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Dermoscopy of erythrodermic pityriasis rubra pilaris p. 500
Sheetanshu Kumar, Keshavamurthy Vinay, Bishan D Radotra
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