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   Table of Contents - Current issue
Coverpage
March-April 2019
Volume 10 | Issue 2
Page Nos. 97-224

Online since Friday, March 15, 2019

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REVIEW ARTICLES  

Update on management of polycystic ovarian syndrome for dermatologists Highly accessed article p. 97
Shalini Gainder, Bharti Sharma
DOI:10.4103/idoj.IDOJ_249_17  
Polycystic ovarian syndrome (PCOS) is the commonest endocrine disorder in women having wide range of clinical manifestation. These women may present with reproductive, dermatological, metabolic, psychological, or neoplastic implications from adolescence to menopause. The common dermatological manifestations include hirsutism, acne, alopecia, or acanthosis nigricans. Women presenting with these dermatological manifestations must be evaluated for PCOS. A multidisciplinary team approach involving a reproductive endocrinologist, dermatologist, psychologist/psychiatrist, dietician, and sometimes a bariatric surgeon should be undertaken for long-term management of these patients. Unless metabolic and underlying endocrinal disturbances arecorrected and simultaneous life-style modification is adopted, cosmetic treatment would give only temporary relief.
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Recent laboratory advances in diagnostics and monitoring response to treatment in leprosy Highly accessed article p. 106
Utpal Sengupta
DOI:10.4103/idoj.IDOJ_260_18  
The present review briefly summarizes the highlights of the recent advances in Mycobacterium leprae-specific tests for early diagnosis of leprosy. In addition to establishing the diagnosis of clinical cases of leprosy, these tests have also been used to detect subclinical infections in endemic population. Several attempts have been made from 1980 onward for standardization of specific diagnostic assays for early detection of leprosy. Brief account about the development and use of these assays has been described in this review article.
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ORIGINAL ARTICLES Top

Dietary protein deficit and deregulated autophagy: A new Clinico-diagnostic perspective in pathogenesis of early aging, skin, and hair disorders Highly accessed article p. 115
Suruchi Garg, Ankita Sangwan
DOI:10.4103/idoj.IDOJ_123_18  
Background: Diet has an important role to play in the well-being of human body. Aims: The study intends to establish the “hypothesis of conscious, selective, and self-destruction i.e., deregulated autophagy of skin and hair in low dietary protein scenario” by determining the facial profile, clinical presentation, and histopathological correlation of deficient protein intake and missing of meals in a tertiary care aesthetic skin institute. Methods: A total of 98 patients of skin- and hair-related complaints were enrolled in the study and a histopathological correlation was established by skin and scalp biopsies in high and low protein groups. Results: A significant number of subjects (68.4%) were taking less than half of the recommended daily allowance of proteins and faced problems like hair fall, acne, pigmentation, vitiligo, hirsutism, melasma, and premature aging. Subjects missing breakfast were found to have hypothyroidism, diffuse hairfall, autoimmune disorders like vitiligo, lichen planus, and alopecia areata. Histopathological images from submental area showed loose and fragmented collagen in high carbohydrate group in comparison to high protein group where thick, uniformly stained collagen bundles were found in dermis. Histopathology of scalp tissue showed chronic perifollicular inflammatory infiltrate and fibrosis in high carbohydrate group which was absent in histopathology specimen of high protein group. Patients taking early and nutrient-rich breakfast had higher mean protein intakes and less severe skin and hair problems suggesting a role of circadian rhythm as well. Conclusion: Dietary protein adequacy and early breakfast have significant role in preventing self-destruction or deregulated autophagy in trichology and cosmetic dermatology and may prevent various autoimmune, inflammatory, and metabolic diseases.
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Oral antifungal therapy: Emerging culprits of cutaneous adverse drug reactions Highly accessed article p. 125
Raju G Chaudhary, Santoshdev P Rathod, Ashish Jagati, Dhara Zankat, Arwinder K Brar, Bansri Mahadevia
DOI:10.4103/idoj.IDOJ_353_18  
Introduction: Antifungals are one of the most widely used drugs in dermatology practice for dermatophytosis. Oral antifungal therapy against superficial dermatophytosis is generally associated with a low incidence of adverse events in an immunocompetent population. However, lately, cutaneous adverse drugs reactions (CADRs) have been reported with varying incidence rates in the patients on oral antifungal therapy with many uncommon morphological patterns. The present, observational study was conducted over a period of 4 months to report the cases which presented with antifungal therapy-associated CADRs. Materials and Methods: It was an observational, prospective study carried out at a tertiary care center in Western India over a period of 4 months. All patients diagnosed with superficial dermatophytic infections (clinically and fungal hyphae seen on 10% potassium hydroxide mount) started on oral antifungal therapy, presenting with cutaneous manifestation other than the primary dermatophytosis were included. The incidence of CADRs due to oral antifungal agents and the percentage of each clinical type of the CADR observed was calculated. Results: The incidence of CADRs due to antifungal drugs was 8.3 per 10,000 patients. In total, 35 cases were reported out of 4,208 cases of dermatophytosis. Terbinafine was the most common causative drug, accounting for nearly 83% of cases, followed by itraconazole for 14% cases, and griseofulvin for 2.8% of cases. Conclusion: The role of systemic antifungals must not be overlooked in any patient with a CADR and should be reported as a trend indicator.
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Association of Vitamin D receptor gene polymorphisms and serum 25-Hydroxy Vitamin D levels in vitiligo – A case-control study p. 131
Iffat Hassan, Yasmeen J bhat, Sabhiya Majid, Peerzada Sajad, Farhan Rasool, Rawoof A Malik, Inam Ul Haq
DOI:10.4103/idoj.IDOJ_97_18  
Background: Vitamin D has stimulatory and protective effects on melanocytes and acts through its nuclear vitamin D receptor (VDR) on target cells. Various single-nucleotide polymorphisms (SNPs) in VDR genes have been described. Aims: The aim was to study and compare the association of SNP of BsmI/Apa-I/TaqI/FokI/Cdx2 in VDR gene as well as the plasma vitamin D levels in vitiligo patients and healthy controls. Methods: This was a case-control study, in which 100 patients of vitiligo and an equal number of healthy individuals were studied. The VDR polymorphisms of Bsm I, Apa-I, TaqI, fok I, and cdx2 were investigated, after extraction of genomic DNA by rapid capillary polymerase chain reaction with melting curve analysis, and 25 hydroxy vitamin D levels were measured in cases and controls. Results: The frequency of genotypes (SNP FokI and cdx2) was higher in the patient group versus controls (P = 0.002). The genotype frequency (TaqI and Apa-I) was higher in the patients than the controls for the Tt genotype, but not significantly higher (48% vs. 39%, P= 0.1431). The difference between the groups in frequency of the genotype Aa(TaqI and Apa-I) was statistically significant (P = 0.0001 and P= 0.033). Statistically significant difference was also observed in Apa-I-evaluated alleles in cases when compared to controls (P = 0.0001). There was no significant difference in serum vitamin D levels between various genotypes among cases and controls. Out of 100 cases, 10 were found to have vitamin D levels of >30 ng/ml, 15 had levels between 20 and 30 ng/ml, 52 had ≤20 ng/ml, and 23 ≤ 10 ng/ml, respectively. Limitations: Since the skin biopsies were not taken from the lesions of vitiligo, the correlation of serum levels with tissue levels of VDR gene was not possible and the role of vitamin D supplementation was not evaluated. Conclusion: The single nucleotide gene polymorphisms of various VDR genes as found in the cases might lead to vitamin D deficiency, due to VDR dysfunction, which in turn could increase the susceptibility to develop vitiligo.
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Awareness of cosmetic dermatology procedures among health workers in a Tertiary Care Hospital p. 139
Deeptara P Thapa
DOI:10.4103/idoj.IDOJ_70_18  
Introduction: Cosmetic dermatology is a branch of dermatology which deals with the enhancement of beauty. There is a rise in cosmetic dermatological procedures throughout the world, but its awareness is limited not only in the general population but also among the health workers. Materials and Methods: We conducted a cross-sectional questionnaire-based study to know the knowledge and awareness of cosmetic dermatological procedures among health workers in a hospital setting. Results: There were a total of 155 respondents. The maximum number of respondents belonged to age group of 20–30 years (65.2%). Female respondents were 66% and males were 34%. Of the total respondents, 39% were medical students, 31% doctors, 23% nurses, 6% OPD assistants, and 1% ward maids. Hinduism was practiced by 91% of the respondents. About 84.5% of subjects were aware of cosmetic dermatological procedures. Regarding the source of information, 34.2% implicated textbooks. According to 53.5% participants, cosmetic dermatological procedures are done by a dermatologist. Around 59.4% responded that they were aware of many procedures such as botox injections, laser hair removal, hair transplant, and chemical peeling; 51% were aware of risks associated with procedures, such as allergy, burns, and pigmentation; 44.5% rated the facility as good; 31% believed that outcome of the procedures is different in Nepal as compared to a foreign countries. About 23.9% thought public disposition will change if they underwent the procedures. Around 11.6% thought this shall negatively affect them; however, 53.5% believed it would be socially acceptable. About 78.1% thought that these procedures are done only in cities with 62.6% believing it is commonly done by high-class economic status people. About 73.5% respondents believed that this was adopted by literate people; 7.1% were concerned about taboos against cosmetic dermatosurgical procedures; 84.5% agreed that there should be awareness program on these procedures. Conclusion: We found lack of awareness, knowledge, attitudes, and disposition about cosmetic dermatosurgical procedures among health workers. Further community-based population studies and awareness programmes should be carried out regarding this aspect.
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An observational study to describe the clinical pattern of dermatological emergencies from emergency department and intensive care unit: Our experience from a tertiary care hospital in Northern India p. 144
Debdeep Mitra, Ajay Chopra, Neerja Saraswat, Reetu Agarwal, Sushil Kumar
DOI:10.4103/idoj.IDOJ_318_18  
Background: A large number of skin diseases have the potential to culminate into potentially fatal “acute skin failure.” The concept of dermatological intensive care unit (ICU) has largely evolved as a result of increased number of emergencies encountered by dermatologists these days. Dermatological emergencies comprise 8–20% of cases presenting to the emergency department. A wide variety of these conditions require a collective effort by intensivists, surgeons, physicians, and nursing staff in association with the treating dermatologist to reduce the associated mortality and morbidity. Dermatology ICU along with state-of-the-art nursing care is required to manage these cases, which result in acute skin failure. Materials and Methods: A prospective study conducted in a tertiary care center with a round the clock emergency department and a state-of-the-art dermatology ICU over a period of 12 months. Patients requiring primary dermatological consultation in the emergency department and patients admitted in the dermatology intensive care unit were evaluated, and their clinical variables were statistically analyzed. Results: In total, 327 cases were seen in the emergency department, out of which 54 (16.5%) cases were admitted in dermatology ICU, 239 (73.1%) were treated as outpatient cases, and 34 (10.4%) were managed as inpatients in other wards of the hospital. The most common condition in out-patient cases was acute urticaria and angioedema in 71 (29.7%), while vesiculobullous disorders in 16 (29.6%) patients was the most common condition requiring admission in dermatology ICU. Conclusions: At present, only few studies are available in the literature on the spectrum of dermatological disorders reporting to emergency department, and further requiring intensive care under ICU setting. This prospective study highlights the varied patterns of dermatosis reporting to emergency outpatient department and those managed in the ICU.
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Idiopathic localized involutional lipoatrophy: A retrospective study of 12 cases p. 149
Reena K Sharma, Mudita Gupta, Lalita Negi
DOI:10.4103/idoj.IDOJ_40_18  
Background: Idiopathic localized involutional lipoatrophy (ILIL) is focal loss of subcutaneous tissue without any clinical or histopathological inflammation with spontaneous regression. Objective: To retrospectively study clinical features and evolution of lesions in patients diagnosed with idiopathic localized lipoatrophy presenting to the department of dermatology of two district hospitals of Himachal Pradesh. Materials and Methods: A retrospective study of clinical patterns and evolution of ILIL was done in patients presenting with this condition in two district hospitals in the past 4 years (October 2013–September 2017). All clinically suspected and histopathologically confirmed cases of idiopathic localized lipoatrophy were included in the study. All cases with history of antecedent injections, vaccination, or medications before the development of lesion and inflammatory lipoatrophy on histopathology were excluded. Results: We found a total of 12 patients with ILIL. About 66% were children (8/12), 3 (25%) young females, and 1 (8%) young adult male. The most common site involved was buttock in 9 (75%) cases followed by a single case each (8%) with lesion on arm, face, and lower back. Two children and one adult were having bilateral involvement (25%), whereas the remaining had unilateral lesions. Lipoatrophy in 8 (66%) patients decreased spontaneously (with placebo) within 4–12 weeks duration whereas 4 required treatment. None required surgical or cosmetic interventions. Limitations: Small sample size and nonavailability of immunohistochemistry reports in all patients. Conclusion: ILIL is a rare form of lipoatrophy with specific loss of adipose tissue without any inflammatory changes. We concluded that ILIL is an underreported entity, probably due to its spontaneous resolution.
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BRIEF REPORT Top

Study on assessment of quality of life and depression in patients of vitiligo p. 153
RahulKrishna S Kota, Rita V Vora, Jagdish R Varma, Suresh K Kota, Trusha M Patel, Jaishree Ganjiwale
DOI:10.4103/idoj.IDOJ_14_18  
Context: Vitiligo is an autoimmune pigmentary disorder characterized by localized or generalized depigmentation of the skin. It is associated with significant stigma and has impact on patient's quality of life (QoL) and psychological wellbeing. Aims: To see the variance in QoL and level of depression in vitiligo patients with extent of vitiligo. Materials and Methods: Vitiligo patients aged ≥18 years attending OPD were included in the study. Impairment in QoL was assessed by administering DLQI (Dermatology Life Quality Index) and VIS22 (Vitiligo Impact Scale22). Depression was assessed by administering QIDSSR16 (Quick Inventory of Depressive Symptomatology). The Vitiligo Area Scoring Index (VASI) was calculated based on clinical examination. Results: One hundred and fifty patients enrolled. Most common age group was 18–30 years. Mean DLQI, VIS22, QIDSSR16 scores were 7.02, 16.37, 5.87, respectively. QoL was affected to some extent in 85.3% and 86.7% according to the DLQI and VIS22, respectively. Depression was seen in 44%. Coclusion: Young patients showed higher impairment in QoL and also higher levels of depression. It would be useful to offer psychiatric consult and counseling in addition to specific treatment.Context: Vitiligo is an autoimmune pigmentary disorder characterized by localized or generalized depigmentation of the skin. It is associated with significant stigma and has impact on patient's quality of life (QoL) and psychological wellbeing. Aims: To see the variance in QoL and level of depression in vitiligo patients with extent of vitiligo. Materials and Methods: Vitiligo patients aged ≥18 years attending OPD were included in the study. Impairment in QoL was assessed by administering DLQI (Dermatology Life Quality Index) and VIS22 (Vitiligo Impact Scale22). Depression was assessed by administering QIDSSR16 (Quick Inventory of Depressive Symptomatology). The Vitiligo Area Scoring Index (VASI) was calculated based on clinical examination. Results: One hundred and fifty patients enrolled. Most common age group was 18–30 years. Mean DLQI, VIS22, QIDSSR16 scores were 7.02, 16.37, 5.87, respectively. QoL was affected to some extent in 85.3% and 86.7% according to the DLQI and VIS22, respectively. Depression was seen in 44%. Conclusion: Young patients showed higher impairment in QoL and also higher levels of depression. It would be useful to offer psychiatric consult and counseling in addition to specific treatment.
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CASE REPORTS Top

Barber Say Syndrome (A new case report) p. 158
Mehrdad Rezaei, Susan Zamani, Hourvash Haghighinejad
DOI:10.4103/idoj.IDOJ_68_18  
Barber Say syndrome (BSS) is a rare ectodermal dysplasia with neonatal onset characterized by congenital generalized hypertrichosis, atrophic skin, ectropion and macrostomia. A literature review showed less than 20 previously reported cases of Barber Say syndrome. This presentation reports a one day old female with syndrome face, low hairline, coarse face, macrostomia, thin upper lip, bilateral ectropion and hypertelorism, hypertrichosis, senile skin appearance, hypoplastic nipples and one area of mild skin atrophy. These findings are consistent with BSS.
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Thyroxine-Induced preradial myxedema p. 162
Mary Zothanpuii Chhangte, Shikha Verma, Binod Kumar Thakur, Anita Marak
DOI:10.4103/idoj.IDOJ_161_18  
Localized myxedema is most commonly described in patients with hyperthyroidism, especially Graves' disease. Although pretibial myxedema generally appears as indurated plaques on the shins, it has also been rarely reported in other areas such as the face, shoulders, arms, and abdomen. We report a rare case of preradial myxedema in a hyperthyroid patient who was taking thyroxine post thyroidectomy for goiter. To the best of authors' knowledge, this is the first case of preradial myxedema, due to long-term intake of thyroxine, reported in the English dermatological literature.
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Chronic relapsing cutaneous leishmaniasis in an elderly female: A rare clinical presentation from a nonendemic area p. 165
Shagufta Rather, Safia Bashir, YJ Bhat, Iffat Hassan
DOI:10.4103/idoj.IDOJ_264_17  
The presentation of cutaneous leishmaniasis (CL) varies from asymptomatic erythematous papules to nodulo-ulcerative forms over the exposed parts of body, generally healing slowly in 3–12 months. Besides, rare and atypical presentations of disease are being reported that pose both a diagnostic and therapeutic challenge especially in nonendemic areas. There has been an increase in the incidence of CL in our region over the past decade, and most of our patients belong to district Kupwara which is the north-most district of Kashmir valley, situated at an altitude of 5300 feet above sea level sharing borders with Pakistan-administered Kashmir. Herein, we report a case of an elderly female from a nonendemic area who had a relapse of cutaneous disease at a previously treated site and came to us with an atypical presentation of more than 2 years duration.
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Well-differentiated squamous cell carcinoma arising in syringocystadenoma papilliferum p. 168
MP Singh, SV Choudhary, JK Chaurasia
DOI:10.4103/idoj.IDOJ_43_18  
Syringocystadenoma papilliferum (SCAP) is a hamartoma of apocrine sweat gland origin, occurring predominantly in children, in the head and neck region. SCAP can arise or coexist with both benign and malignant tumors. We report herein an extremely rare case of squamous cell carcinoma (SCC) arising in SCAP growth located in unusual supragluteal region in an elderly Indian male. A wide surgical excision of the growth was performed which upon histopathological examination revealed the confirmatory diagnosis. SCC arising in SCAP is unusual, and only two histologically confirmed cases have been previously reported in the literature. This case report emphasizes about extremely rare malignant transformation of SCAP, which should be kept in mind while evaluating a suspicious skin lesion.
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Total dystrophic onychomycosis due to syncephalastrum racemosum – A rare cause and its novel treatment option p. 171
Prasenjeet Mohanty, Siddhartha Dash, Liza Mohapatra, Monica Jain
DOI:10.4103/idoj.IDOJ_155_18  
Onychomycosis is a fungal infection of the nail caused by dermatophytic (99%) and/or non-dermatophytic (1%) (including yeasts) infections of the nailplate. Among the non-dermatophytes, the yeast Candida albicans, Candida tropicalis, and other molds like Scopulariopsis spp., Scytalidium spp., Fusarium spp., and Aspergillus spp. may be responsible. Herein, we report a case of total dystrophic onychomycosis in a 41-year-old female, caused by Syncephalastrum racemosum and its complete improvement with a combination of oral pulse itraconazole and 1064 nm Q-switched Nd-YAG laser. This case is being reported due to the rarity of causative organism for onychomycosis and a novel approach in its treatment.
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Zinc Therapy in Treatment of Symptomatic Oral Lichen Planus p. 174
Nallan CSK Chaitanya, Suvarna Chintada, Pallavi Kandi, Sushma Kanikella, Anuja Kammari, Rutuja S Waghamare
DOI:10.4103/idoj.IDOJ_230_18  
Lichen planus is a chronic inflammatory disease, which involves skin, mucous membrane, and nails. Prevalence of oral lichen planus varies between 0.5% and 2.6% of adult population worldwide with overall female preponderance. It is considered as a potentially malignant disorder with rate of transformation to oral cancer varying between 0.5% and 2%. Oral lichen planus may either be unilateral or bilateral, or may involve multiple sites. Although the exact etio-pathogenesis of this condition is unknown, it is believed that stress, use of medications, dental fillings, genetics, immunity, and hypersensitivity reactions may contribute to its pathogenesis. It is a T-cell-mediated autoimmune disorder in which CD8+ T cells are involved which release various cytokines such as tumor necrosis factor-α and interleuking-12 leading to disruption of basement membrane integrity. Zinc activates caspase-3 and DNA fragmentation, resulting in the apoptosis of keratinocytes. By prevention of matrix metalloproteinase (MMP)-1 activation, it inhibits T-cell accumulation in oral lichen planus, and by inhibiting MMP-9 it prevents cleavage of collagen IV resulting in maintaining the integrity of the basement membrane. The present case series describes the use of oral zinc acetate (50 mg) in patients having symptomatic oral lichen planus with favorable outcome in terms of size of lesion and global index score.
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LETTERS TO THE EDITOR Top

Cutaneous rhinosporidiosis presenting as cutaneous horn and verrucous plaque p. 178
Chandra S Sirka, Gaurav Dash, Swetalina Pradhan, Manas Baisakh
DOI:10.4103/idoj.IDOJ_106_18  
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Graham–Little–Piccardi–Lasseur syndrome p. 180
Gunjan Verma
DOI:10.4103/idoj.IDOJ_360_17  
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Speckled acral hypopigmentation: A new pigmentary disorder or an unknown presentation of a known disorder? p. 182
Sanjay Singh, Kanika Sahni, Sudheer Arava
DOI:10.4103/idoj.IDOJ_139_18  
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Progressive symmetrical erythrokeratoderma associated with punctate palmoplantarkeratoderma p. 183
Anup K Tiwary, Piyush Kumar
DOI:10.4103/idoj.IDOJ_105_18  
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Congenital bathing trunk nevus with meningomyelocele p. 186
Vichithra Mohandoss, Vijai Williams, Namita Ravikumar, Karthi Nallasamy
DOI:10.4103/idoj.IDOJ_256_18  
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Dermatoscopic features of prurigo nodularis p. 187
Pragya A Nair, Trusha Patel
DOI:10.4103/idoj.IDOJ_224_18  
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SKINDIA QUIZ Top

SkinIndia Quiz 50: Solitary growth on the arm Highly accessed article p. 190
Krishna Talukdar, Debdeep Mitra, Neerja Saraswat, Ajay Chopra
DOI:10.4103/idoj.IDOJ_292_17  
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RESEARCH SNIPPETS Top

Clinical Trial Designs p. 193
Brijesh Nair
DOI:10.4103/idoj.IDOJ_475_18  
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THROUGH THE LENS Top

Subungual exostosis – Clinical, radiological, and histological findings p. 202
Pratap Chandra Das, Shahid Hassan, Piyush Kumar
DOI:10.4103/idoj.IDOJ_104_18  
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Primary systemic amyloidosis mimicking rhinophyma p. 204
Ankita Agrawal, Meena Makhecha, Kinjal Rambhia
DOI:10.4103/idoj.IDOJ_163_18  
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THROUGH THE DERMOSCOPE Top

Dermoscopy of glomus tumor p. 206
Piyush Kumar, Anupam Das
DOI:10.4103/idoj.IDOJ_88_18  
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Dermoscopy of primary cutaneous B-cell lymphoma p. 208
Paul M Hoesly, Jason C Sluzevich, Mark A Cappel
DOI:10.4103/idoj.IDOJ_39_18  
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Dermoscopy of Tinea Manuum p. 210
Deepak Jakhar, Ishmeet Kaur, Sidharth Sonthalia
DOI:10.4103/idoj.IDOJ_95_18  
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HISTORY Top

Historic research about the first dermatology book and its author: Hieronymus Mercurialis p. 212
Alberto Sanchez-Garcia, Elena Garcia-Vilarino
DOI:10.4103/idoj.IDOJ_377_18  
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CONFERENCE PROCEEDINGS Top

South Asian Epidemic of Antifungal Therapeutic Failures: Congress Proceedings and Take-home Messages. First International Congress of SAARCUM: South Asian Alliance against Recalcitrant Cutaneous Mycosis. 17 November 2018, Medanta – The Medicity, Gurugram, India p. 214
Parul Aggarwal, Mahima Agrawal, Sidharth Sonthalia, Dharmendra Arora, Poonam Sharma
DOI:10.4103/idoj.IDOJ_497_18  
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