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   Table of Contents - Current issue
January-February 2020
Volume 11 | Issue 1
Page Nos. 1-134

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Melanonychia: Etiology, Diagnosis, and Treatment p. 1
Archana Singal, Kavita Bisherwal
Melanonychia is a very worrisome entity for most patients. It is characterized by brownish black discoloration of nail plate and is a common cause of nail plate pigmentation. The aetiology of melanonychia ranges from more common benign causes to less common invasive and in situ melanomas. Melanonychia especially in a longitudinal band form can be due to both local and systemic causes. An understanding of the epidemiology, pathophysiology and clinical details is necessary for adequate patient care and counseling. It not only helps in the early recognition of melanoma but also prevents unnecessary invasive work up in cases with benign etiology. An early diagnosis of malignant lesion is the key to favourable outcome. Though there are no established guidelines or algorithms for evaluating melanonychia, a systematic stepwise approach has been suggested to arrive at a probable etiology. We, hereby, review the aetiology, clinical features, diagnostic modalities and management protocol for melanonychia.
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Teledermatology and its current perspective p. 12
Paola Pasquali, Sidharth Sonthalia, David Moreno-Ramirez, Pooram Sharma, Mahima Agrawal, Somesh Gupta, Dinesh Kumar, Dharmendra Arora
Teledermatology is one of the most important and commonly employed subsets of telemedicine, a special alternative to face-to-face (FTF) doctor--patient consultation that refers to the use of electronic telecommunication tools to facilitate the provision of healthcare between the “seeker” and “provider.” It is used for consultation, education, second opinion, and monitoring medical conditions. This article will review basic concepts, the integration of noninvasive imaging technique images, artificial intelligence, and the current ethical and legal issues.
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Chlamydia Trachomatis associated reactive arthritis: A urinary PCR based study p. 21
Megha Sharma, Susmita Sharma, Aman Sharma, Kusum Sharma
Background and Objective: Chlamydia trachomatis is increasingly being associated with reactive arthritis (ReA). The present study was undertaken to assess the role of C. trachomatis in patients with ReA since such data is lacking from the Indian population. Materials and Methods: PCR using specific primers for C. trachomatis was carried out from urine samples of 65 patients with ReA, 20 of other inflammatory arthritis, and 20 healthy controls. Results: C. trachomatis DNA was detected from urinary samples with PCR in 24 (36%) of 65 ReA patients. PCR was negative in the patients of other inflammatory arthritis as well as in normal healthy control group. Out of the 24 patients with urinary PCR positivity, 14 (58.33%) were males and 10 (41.66%) were females. Conclusion: Urinary PCR plays an important role in rapid diagnosis of ReA associated with C. trachomatis.
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Risk factors associated with head lice infestation in rural pediatric patients p. 25
Neerja Saraswat, Pooja Shankar, Ajay Chopra, Barnali Mitra, Sushil Kumar
Introduction: Head louse infestation is a common parasitic disease in pediatric age group. It is common in collective centers such as schools, garrisons, campuses and old age homes. It is worldwide in distribution with no strict limitation with respect to age, gender and race. Aims: Present study was conducted to investigate the socio-economic and lifestyle risk factors for head louse infestation in pediatric patients. Materials and Methods: An observational descriptive study at a tertiary care hospital in rural Uttar Pradesh over a period of 1 year wherein measurement of disease/risk factors associated with head louse infestation was performed. It was carried out in all children between 5 and 15 years of age using a pre-validated questionnaire. The method of convenience sampling was used and multiple logistic regression was run to account for potential confounding variables using SPSS software. Results: A total of 165 (71.1%) females and 67 (28.8%) males were infested. Most common age group affected was between 5 and 7 years where 97 (41.8%) children were infected. Ninety-five (40.9%) children were in fourth to seventh standards. Parents of 137 (59%) children were not formally educated. Eighty-one (34.9%) children had six members in the family while per capita income was between 5000 and 2500 in families of 139 (59.9%) children. Eighty-seven (37.5%) children had hair length up to shoulders. One twenty-eight (55.1%) children had no family member affected. Seventy-six (32.7%) children took bath twice a week only. Conclusion: Social and economic factors as well as lifestyle and education level of patients play a significant role in epidemiology of head lice.
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Psoriatic nephropathy and its correlation with hs-CRP: A case control study p. 29
Ishmeet Kaur, Vijay Gandhi, Alpana Raizada, Sambit Nath Bhattacharya, Ashok K Tripathi, Deepak Jakhar
Background: Psoriasis is a multisystem disorder associated with various systemic diseases such as cardiovascular diseases, diabetes mellitus and metabolic syndrome. Renal involvement in patients with psoriasis is sparsely studied and its association is still unclear. Aim: The aim of this article was to study causal attributable renal involvement in patients with psoriasis and factors affecting the same. Methods: Fifty patients with documented psoriasis were recruited after excluding any secondary causes of renal disease. They were subjected to routine investigations along with hs-CRP and specific investigations for kidney function including urine albumin creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR). The eGFR and ACR of the patients were compared with 50 age- and sex-matched controls. Association with any disease-related factors such as severity and duration were assessed. Renal biopsy was planned in patient with ACR >500 mg/g creatinine. Results: The mean eGFR (IQR) (ml/min/1.73 m2) of the case group was found to be 80.00 (71.00–95.75) and in the control group was 88.00 (75.25–99.00). This difference was not significant (P = 0.206). However, in the age group of > 30 years, the eGFR of disease group (78.50 ± 17.94) was significantly lower than that in the control group (88.96 ± 17.01, P = 0.023).The mean urine ACR (mg/g) in the disease group was found to be 13.359 ± 26.01 while that in the control group was found to be 5.66 (3.40–8.08), and the difference was not found to be clinically significant. Four patients with psoriasis had microalbuminuria as opposed to none of the controls. Conclusion: Subclinical albuminuria was found in 8 per cent of patients with psoriasis. Glomerular dysfunction with statistically significant reduction in eGFR was seen in psoriasis in age group of more than 30 years and those who had a long-standing disease. The renal involvement had positive correlation with hs-CRP indicating the role of inflammatory milieu. Further large-scale cohort studies would help assess this aspect in further details. Limitation of the Study: Sample size was small. Large-scale studies would be required to further substantiate these observations.
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Comparative study of clinical and dermoscopic features in nail psoriasis p. 35
Naphisabet Wanniang, Annam Navya, Varadraj Pai, Rakhi Ghodge
Background, Aims, and Objectives: Nail changes have been reported in approximately 40% of psoriasis patients. Occasionally nail psoriasis may be the sole finding or the first presentation of the disease. Assessment of the nail changes associated with psoriasis can be done clinically, ultrasonographically, and most recently using a dermoscope. The aim of this study is to assess the dermoscopic features in nails of psoriasis as well as to compare the dermoscopic with the clinical findings. This study has also assessed the correlation between disease duration and the severity of skin and nail involvement. Materials and Methods: A total of 50 patients with psoriatic nail changes were recruited in the study. The psoriasis area severity index (PASI) was used to assess the severity of the disease. The nail psoriasis severity index (NAPSI) was used to determine the severity of nail involvement. The patient's nails were examined both clinically and dermoscopically. Results: Pitting was the commonest feature (84%) noted both clinically and dermoscopically. A statistically significant higher NAPSI score (P < 0.05) was obtained by a dermoscope than by clinical examination. Salmon patch and splinter hemorrhage were better visualized using a dermoscope than by clinical evaluation (P < 0.05). The duration of the disease had a strong positive correlation (R = 0.901) with the duration of nail involvement whereas there was a weak correlation between the duration of the disease and the clinical NAPSI (R = 0.23) and dermoscopic NAPSI (R = 0.28). A weak positive correlation (R = 0.3) was noted between the PASI and NAPSI scores. Conclusion: Dermoscopy of nails proved to be an efficient, supportive, easy, noninvasive method that provides a better insight into the subtle nail changes in psoriatic patients, which may have been missed clinically.
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A split face comparative study of safety and efficacy of microneedling with tranexamic acid versus microneedling with Vitamin C in the treatment of melasma p. 41
Ashok Menon, Hafsa Eram, Prashanth R Kamath, Saumya Goel, Amita Murali Babu
Introduction: Melasma is a common pigmentary disorder affecting the face. Although a few risk factors have been identified, the exact pathogenesis remains elusive. Many treatment modalities have been tried, but none have been completely successful. Aim: To compare safety and efficacy of microneedling with Tranexamic acid versus microneedling with Vitamin C in the treatment of melasma. Materials and Methods: It was a split face, comparative study conducted on 30 female melasma patients. After obtaining informed consent, microneedling with Tranexamic acid was done on left side and microneedling with Vitamin C was done on right side of face. The improvement was evaluated on the basis of clinical photographs, MASI, Physician Global Assessment (PGA) and Patient Global Assessment (PtGA) at each visit (0, 4 and 8 weeks). Z test was used to test the significant difference in the means of the 2 groups at 4 weeks and at 8 weeks. Results: At the end of 8 weeks, MASI, PGA and PtGA showed improvement with both tranexamic acid and vitamin C. However the improvement was more with tranexamic acid than with vitamin C, although not statistically significant. Conclusion: Both TXA and Vitamin C are effective and safe treatments for melasma. But, TXA was found to be more effective.
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Clinicomycological study of dermatophytosis in a tertiary care hospital in eastern India: A cross-sectional study p. 46
Bhabani S. T. P Singh, Tapaswini Tripathy, Bikash R Kar, Arunima Ray
Introduction: Dermatophytosis is a fungal infection of the skin, hair, and nails. In the past several years, it has emerged as a general public health problem in our country. Studies from different regions reveal varying patterns of etiological distribution of the disease. Aims and Objectives: To estimate the prevalence of different fungal species associated with dermatophytosis and to find out any possible association of the type of fungus with different clinical parameters of the disease. Materials and Methods: This was a cross-sectional study among 311 clinically diagnosed dermatophytosis cases from a tertiary care center in eastern India. Potassium hydroxide (KOH) mount and fungal culture were done from samples of skin, hair, and nails, and various clinical parameters were analyzed. Results: There was a male preponderance among cases and maximum patients belonged to third decade of life. Most common presentation was tinea corporis et cruris (39.5%). Family history was positive in 48.8% of cases. Trichophyton mentagrophytes was the most common fungal species (79.91%) grown in culture followed by Trichophyton rubrum (13.53%). Majority of patients had a mild body surface area involvement. We did not find statistically significant association of any clinical parameters with type of organism isolated. Conclusion:Trichophyton mentagrophytes was the most common isolated fungal species. This is in contrast to several studies where T.rubrum was the frequently found organism. There was no significant association of any clinical parameters like body surface area, number of sites, or duration of diseasewith fungal species isolated in culture.
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Real-world efficacy and safety of apremilast monotherapy in the management of moderate-to-severe Psoriasis p. 51
Bela J Shah, Deval Mistry, Navin Chaudhary, Shikha Shah
Introduction: Apremilast is the new oral drug in the management of moderate-to-severe plaque psoriasis with well-established effectiveness and safety in long-term clinical trials and a few real-world studies. However, its effectiveness and safety in Indian setup have not been reported yet. Materials and Methods: This was retrospective, single-center, longitudinal, observational cohort study where the total study period was 24 weeks. Effectiveness parameters were the proportion of patients achieving psoriasis area and severity index (PASI) 50, 75, 90, and 100 response at week 16 and 24. Safety was measured as the proportion of patients reporting ≥1 adverse event (AE) during the study period. Results: Data of a total of 70 patients were included in our study. At week 16, 76.92%, 41.53%, 15.38%, and 6.15% patients achieved PASI 50, 75, 90, and 100, respectively. At week 24, 81.53%, 58.46%, 29.23%, and 10.76% patients achieved PASI 50, 75, 90, and 100, respectively. Mean percentage reduction in PASI was 67% at week 24 and DLQI score was reduced significantly to 3.4 from mean baseline DLQI score of 10.8 (P < 0.001). 40% of patients reported ≥1 AE during the study period. 5 out of 70 patients discontinued apremilast due to AE. Nausea was most common AE reported by 21.4% patients followed by diarrhea (18.57%), headache (17.4%), vomiting (8%), weight loss (7.69%), myalgia (6.15%), and gastritis (6.15%). Most of the AEs were of mild-to-moderate severity. Conclusion: The results of this study support the long-term use of apremilast monotherapy as an efficacious and safe treatment option for the management of moderate-to-severe plaque psoriasis.
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Comparison of efficacy of autologous platelet-rich fibrin versus Unna's paste dressing in chronic venous leg ulcers: A comparative study p. 58
G Yuvasri, Reena Rai
Background: Chronic venous leg ulcers are difficult to treat and recurrences are common. Among various modalities of treatment, platelet-rich fibrin (PRF) has shown promising results in ulcer healing by providing necessary growth factors. Unna's paste dressing has also proven to enhance wound healing. Aim: The aim of this study is to compare the efficacy of autologous PRF versus Unna's paste dressing in chronic venous leg ulcer patients and to compare the mean reduction in ulcer area at the end of 4 weeks. Materials and Methods: Twenty patients with chronic venous leg ulcers were randomly divided into two groups. Group 1: Patients received PRF dressing which was repeated every week for 4 weeks. Group 2: Patients received Unna's paste dressing once a week for 4 weeks. The ulcer size was assessed with the help of photographs, and ulcer area was measured. Results: The mean reduction in the area of the ulcer size in the PRF group was 86.03% and in the Unna's paste group was 71.97%, which was not statistically significant with a P value of 0.223. Conclusion: We conclude that though there was no statistical significance between the groups, PRF showed a significant reduction in ulcer size.
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Co-occurrence of symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) and pigmented Fixed drug eruption (FDE) in a single patient due to Doxycycline: A case report p. 62
Kananbala Sahu, Chandra S Sirka, Swetalina Pradhan, Arpita N Rout
Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE), and fixed drug eruption (FDE) are adverse cutaneous drug reactions. SDRIFE is most commonly associated with the use of beta-lactam antibiotics. There is only one case report describing SDRIFE due to intake of doxycycline in literature. Previously reported case describes the characteristic morphology of well-defined macular erythema over the flexural and intertriginous area. We here in report a 38-year-old male presented with unusual morphology of SDRIFE, and well circumscribed erythematous patches suggestive of FDE on the thigh and back after doxycycline intake. Histopathology was consistent with SDRIFE and FDE respectively. The skin lesions improved with 5 days of 40 mg oral prednisolone. After 6 weeks, drug provocation with doxycycline was done following which patient developed itching and erythema over the older sites. Though there is a single published report of SDRIFE due to doxycycline, our case had additional findings of having pigmented FDE lesions along with flexural lesions of SDRIFE.
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Monilethrix: A report of three cases in children confirmed with dermoscopy p. 65
Remya R Rajamohanan, Biswanath Behera, Prabhakaran Nagendran, Munisamy Malathi
Monilethrix is a rare hereditary disorder affecting hair resulting in hair fragility and alopecia. We report three patients of monilethrix who presented with complaints of sparse and brittle hair from early childhood. All three patients had multiple discrete hyperkeratotic papules over the scalp. Dermoscopy revealed beaded appearance of hair with the presence of elliptical nodes and intermittent constrictions on the hair shafts as well as broken hairs, which were confirmed with routine microscopic examination of hair. Dermoscopy helps in easier and faster diagnosis of monilethrix.
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Pruritic periumbilical plaque as a presentation of a rare perforating dermatosis p. 68
Meghana Bathina, Spandana P Hegde, Akbar A Shanavaz, Prema P Saldanha
Perforating dermatoses are characterized by transepidermal elimination of altered dermal components or foreign particles. Owing to their common clinical presentation as umbilicated papules with a keratotic plug, histopathology and special staining play a very crucial role in the diagnosis. Perforating calcific elastosis, (periumbilical perforating pseudoxanthoma elasticum), an uncommon acquired localized cutaneous dermatoses, is characterized by transepidermal elimination of modified elastic fibres. It is usually seen in middle-aged obese multiparous women as well-defined periumbilical hyperpigmented atrophic plaques. We report a case of a 66-year-old female who presented with a mildly pruritic hyperpigmented periumbilical plaque of 2 years duration. Histopathology studies revealed multiple fragmented, thick, short, and curly eosinophilic fibers; along with granular basophilic material in the dermis, which stained positive for calcium and elastin, thus clinching the diagnosis of perforating calcific elastosis. There were no features of hereditary pseudoxanthoma elasticum. We report this case for its rarity.
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Darier's disease - response to oral Vitamin A: report of a case and brief review p. 72
Megha Sondhi, Sanket Vashist, Vikram K Mahajan
Darier's disease is an uncommon chronic dermatosis of autosomal dominant inheritance with significant psychosocial morbidity and shows unsatisfactory response to several topical and systemic therapies or various resurfacing or surgical procedure. A 24-year-old woman having characteristic asymptomatic and progressive, hyperkeratotic papular lesions involving the scalp, face, upper trunk, and dorsal hands and feet was diagnosed clinicopathologically as Darier's disease. She was treated successfully with oral Vitamin A 25000 IU given twice daily. The response was apparent within 4 weeks and most lesions cleared in 2 months without any adverse effects. Oral Vitamin A provides an effective and safe low-cost therapeutic alternative in Darier's disease, especially when systemic retinoids, the only effective treatment, remain contraindicated or is not tolerated and for maintenance therapy in the long-term.
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Giant congenital melanocytic nevi successfully treated with combined laser therapy p. 79
Jagdish Sakhiya, Dhruv Sakhiya, Mehul Patel, Feral Daruwala
Congenital melanocytic nevi are benign proliferations of cutaneous melanocytes that arise as a result of abnormal growth, development, or migration of melanoblasts. Clinically, the giant congenital nevus is greater than 20 cm in size, pigmented and often hairy. The risk of malignant melanoma for the giant nevi is almost 6%. Fifty percent of the melanomas develop by the age of 2 years and, 80% of the melanomas develop by the age of 7 years. Hence, early management is of paramount importance. Herein, we present a case of giant nevi along with a review of the literature in order to bring awareness among clinicians towards this rare albeit significant entity.
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An exuberant case of necrobiotic xanthogranuloma Highly accessed article p. 83
Sofia Lopes, Nuno Gomes, Artur César, Ana Margarida Barros, Jorge Pinheiro, Filomena Azevedo
Necrobiotic xanthogranuloma (NXG) is a rare form of inflammatory granulomatous disease of the skin characterized by the presence of pruritic to painful lesions, generally located in the periorbital area, although trunk and proximal extremities may also be involved. We report a case of a 69-year-old male patient with extensive involvement of the trunk, upper and lower extremities, and an associated gamma monoclonal gammopathy. The skin biopsy was consistent with the diagnosis of NXG. Necrobiosis lipoidica and granuloma annulare were the major differential diagnosis in this case. We highlight the importance of searching for clinical and histological features that may differentiate these entities, which is crucial to select an adequate therapeutic and surveillance strategy.
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A rare case of extensive pemphigus vegetans p. 87
Ghanshyam K Verma, Gita R Tegta, Anuj Sharma, Mohitpreet Kaur, Sudarshan Sharma
Pemphigus vegetans is a rare variant of pemphigus vulgaris characterized by pustules and/or papillomatous vegetations, preferentially affecting intertriginous and periorificial areas. It has two subtypes: Hallopeau variant and Neumann variant. Cerebriform tongue, a morphology with typical pattern of sulci and gyri over dorsum of the tongue, is a well-known sign in pemphigus vegetans. We are presenting an unusual case of pemphigus vegetans with extensive involvement of mucosae, trunk, extremities including both extensors and flexural areas with verrucous paronychia and fissured tongue. During clinical exam we recognized multiple cutaneous vesicles, erosions and ulcers on mucosal sites. Clinical, histopathological, and direct and indirect immunofluorescence findings were compatible with pemphigus vegetans. Patient had completed her family so treated with intravenous dexamethasone-cyclophosphamide pulse (DCP) regimen with excellent response.
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Congenital triangular alopecia associated with phakomatosis pigmentovascularis type ii along with Klippel Trenaunay syndrome p. 91
Aastha Gupta, Ananta Khurana, Purnima Malhotra, Kabir Sardana
Phakomatosis pigmentovascularis (PPV) is characterized by the association of a vascular nevus with a pigmentary nevus and is divided into five subtypes. PPV type II or Happle's phakomatosis cesioflammea is the most common subtype comprising of nevus flammeus along with pigmentary nevus in the form of aberrant Mongolian spots, nevus of Ota or less frequently nevus of Ito. It is estimated that around 50% of patients with PPV have systemic involvement, most frequently involving the central nervous system and eye. Other associated features include vascular abnormalities such as Sturge-Weber syndrome, and klippel trenaunay syndrome (KTS), and cutaneous lesions such as nevus anemicus (most common), cafe'-au-lait macules, generalized vitiligo and congenital triangular alopecia (CTA). There are only four reports of PPV associated with CTA in literature, and only a single previous report with associated KTS and this association has not been reported previously from India. We describe a case of a 30-year-old male having phakomatosis pigmentovascularis type II along with klippel trenaunay syndrome and associated with congenital triangular alopecia.
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Sun Exposure in Children: Balancing the Benefits and Harms p. 94
Ankur K Jindal, Aman Gupta, Keshavamurthy Vinay, Anuradha Bishnoi
There is a common belief among the laity and even physicians that sun exposure is a useful source of vitamin D. However, despite the fact that sun exposure occurs almost throughout the year in India, vitamin D deficiency is widely prevalent. Although several authors have reported on the duration of sun exposure required to synthesize adequate amounts of vitamin D in the human body, they have not followed a standard and uniform protocol for measurement of sun exposure and vitamin D synthesis. For these and many other reasons, the results are difficult to interpret. The American Academy of Pediatrics (AAP) has clearly stated that infants should be protected from the sun as much as possible and vitamin D requirements should be met through diet and fortified foods rather than deliberate sun exposure. However, this recommendation is frequently ignored in clinical practice. This review aims to summarize the available literature on benefits and harm of unprotected sun exposure in infants and children with a focus on skin phototype IV to VI. Dermatologists and pediatricians in India should counsel parents about the need for sun protection, especially in fair-skinned infants and children.
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Not a drug rash! p. 99
Ananta Khurana, Anusha Katare, Kabir Sardana, Aastha Aggarwal, Ram Kishan Gautam
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Amniotic band syndrome with ectrodactyly-two cases p. 101
Mohabat D Baria
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An elderly male with asymptomatic black staining of hands p. 103
Anuradha Bishnoi, Keshavamurthy Vinay, Sendhil M Kumaran
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“Refractory intertrigo” in an elderly woman Highly accessed article p. 105
Chirag Desai, Arens Mari, Buhles Norbert, Boer-Auer Almut
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Pigmented palmar pits in reticulate acropigmentation of Kitamura p. 108
Yashdeep Singh Pathania, T Muhammed Razmi, Bishan Dass Radotra, Sendhil M Kumaran
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Non-healing vulval ulcer in an immunocompromised female due to concurrent Herpes Simplex Virus and Cytomegalovirus co-infection treated effectively with Valganciclovir p. 111
Preema Sinha, Anwita Sinha, Subramaniyan Radhakrishnan, Siddharth Bhatt
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Rheumatoid neutrophilic dermatosis: The distinct entity with florid presentation p. 114
Indu Kumari, Atul Dongre, Swosti Mohanty
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KID syndrome: A rare genodermatosis p. 116
Vivek Kumar Dey, Animesh Saxena, Shrini Parikh
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An easy, cheap, and user-friendly technique for topical immunotherapy with diphencyprone: Cotton tip injector technique p. 119
Aslı F Kaptanoglu, Züleyha Özgen, Gizem Demir, Elif Cömert
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A chronic penile ulcer in an elderly male p. 120
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit
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Chronic hyperkeratotic acral plaques Highly accessed article p. 123
Shilpi Sharma, Amita Sharma, Neirita Hazarika
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Phthiriasis palpebrarum in a psychiatric patient p. 125
Usha Kim, Chitaranjan Mishra, Mulasthanam Sai Dheera
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Cutaneous metastasis from papillary carcinoma of thyroid p. 126
Suyash S Tomar, Sumit Hajare, Rajesh P Singh
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Reticulate Acropigmentation of Kitamura: A Dermoscopic Perspective Highly accessed article p. 128
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit
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Dermoscopy of telangiectasia macularis eruptiva perstans Highly accessed article p. 131
Smriti Kumar, Deepak Jakhar, Rachita Misri
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Book: Nail disorders: A comprehensive approach p. 133
Chakravarthi Rangachari Srinivas
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