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   Table of Contents - Current issue
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September-October 2020
Volume 11 | Issue 5
Page Nos. 685-880

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REVIEW ARTICLES  

Platelet-rich plasma: The journey so far ! p. 685
Akanksha Kaushik, Muthu Sendhil Kumaran
DOI:10.4103/idoj.IDOJ_369_19  
Platelet-rich plasma (PRP) is an autologous blood product, obtained after blood centrifugation. PRP is rich in growth factors which promote tissue-healing, alter angiogenesis, and possess versatile immunomodulatory effects, in the relative absence of any significant demonstrable adverse effects. Consequently, PRP has found application in multiple specialities in recent years, including dermatology. A literature search was performed on PubMed, Medline database, and Google Scholar, using keywords like platelet-rich plasma (PRP), platelet-concentrated plasma, platelet-rich growth factors, autologous platelet concentrate. Relevant studies were selected, and data was analyzed following extraction. Studies show that PRP has not only been used as an adjunctive modality but has been employed as a stand-alone therapy as well. Multiple authors have reported PRP to be efficacious in disparate dermatological conditions, like alopecia, skin rejuvenation, healing of refractory cutaneous ulcers, and even acne scar management. The strongest evidence so far has been demonstrated in androgenetic alopecia and facial skin rejuvenation. However, routine use in dermatological conditions is hampered by the relative paucity of high-quality evidence and large randomized studies. Furthermore, PRP composition and preparation methods are not yet standardized and even the treatment regimens proposed too vary widely. The present review provides a bird's eye view of the evidence available so far regarding the use of PRP in dermatology. The review focusses more on recent prospective studies, including randomized trials and tries to summarize the evidence in a brief, but comprehensive manner.
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Colchicine in dermatology: Rediscovering an old drug with novel uses Highly accessed article p. 693
Kabir Sardana, Surabhi Sinha, Soumya Sachdeva
DOI:10.4103/idoj.IDOJ_475_20  
Colchicine is an anti-inflammatory agent which has been used for decades in the treatment of gout. The drug has a number of dermatological indications like Psoriasis, Sweet's syndrome, aphthosis, Behcet's disease, erythema nodosum, leukocytoclastic vasculitis and is consistently effective in neutrophilic disorders. Thought it is an affordable with minimal side effects, It has remained underutilized. However, it has novel uses and is being considered in COVID-19 due to its action on IL-1β and IL-6. This article presents a concise and up-to-date review focusing on its mechanisms of action and indications.
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SPECIAL ISSUE ARTICLE Top

The dermlep study I: results of prospective nation-wide survey of the number & Profile of leprosy patients seen by dermatologists in India p. 701
P Narasimha Rao, Santoshdev Rathod, Sujai Suneetha, Sunil Dogra, Sunil Kumar Gupta, Rita Vora, Shushruth Kamoji, Swagta Tambe
DOI:10.4103/idoj.IDOJ_466_20  
Introduction: There is evidence to suggest that there is a mismatch between the number of reported cases of leprosy in India and the number of actual cases in the country. One reason could be that many patients are diagnosed and treated outside the NLEP network and dermatologists may be managing some of these patients not captured by official statistics. To estimate these missing numbers, the DermLep survey was carried out to study the number and profile of leprosy patients seen by dermatologists and their significance. Methodology: The DermLep survey was a questionnaire-based study to be filled in by participating dermatologists from all over India, both in private practice and in medical institutions. Participating dermatologists provided information on old and new leprosy patients seen in their clinic over a 3-month period. Results: Total of 201 dermatologists from 20 states of India participated in the survey. 3701 leprosy patients (M: F ratio 2.1:1) were seen. Of them 46.62% (n = 1680) were new; 22.89% (n = 825) were under-treatment; and 19.65% (n = 708) were post RFT patients. Children <15 years constituted 4.29%, while elderly >60 years were 22.21%. As per WHO classification, MB were 73.36% and PB 28.46%. Of all patients 30.91% had lepra reactions, with T2R being more frequent. While 23.58% of all patients in the survey had G2D; in new patients 17.79%; and in post RFT patients 37% had G2D. Among the 1680 new cases seen, 59% were reported to NLEP by the dermatologists and 41% remained unreported mainly by the private dermatologists, among whom for 20% of the cases they mentioned “no access to register”. Source of MDT was WHO-MDT in 60.09% of new cases and for rest of 39.91% it was private pharmacies where private dermatologists had no access to MDT blister packs. Conclusion: This survey suggests that a good number of new-untreated leprosy patients, treatment defaulters and post RFT cases are managed by dermatologists in India. About 40% of the new patients managed mainly by private dermatologists are not being reported to NLEP for various reasons, and these constitute the “missing numbers” from government statistics. If extrapolated to the large of number of practicing dermatologists in India, these numbers could be very significant. The high percentage of G2D noted in patients surveyed (23.58%) and post RFT patient issues observed need special attention. There is a need to develop access for dermatologists to confidentially report leprosy patients treated at their clinics to the NLEP.
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ORIGINAL ARTICLES Top

Impact of COVID-19 pandemic on dermatology practice in India p. 712
Shashank Bhargava, Rashmi Sarkar
DOI:10.4103/idoj.IDOJ_240_20  
Background: COVID-19 pandemic has disrupted healthcare systems throughout the globe. It has affected dermatology practice to a great extent. Since most of the consultations (except emergencies) in dermatology are deferred as a precautionary measure, dermatologists have taken the route of virtual appointments in order to continue treating patients in the present lockdown state. However, the concept of telemedicine is quite new for doctors as well as for patients in India. Material and Methods: An online questionnaire was circulated among Indian dermatologists which included participant demographics, changes in their practice and teaching during COVID-19, use of virtual or e-health technologies, and attitudes/opinions on their experiences. We also wanted to understand doctor perspectives on their own roles, wellness, and hospital responses to the pandemic. Results: A total of 260 responses from qualified dermatologists of different parts of India were received between 1st and 8th April 2020 and were analyzed. Two-thirds of the respondents were within 10 years of starting practice. Virtual consultations have increased by almost three-fold during the pandemic, which is a major change noticed in the practice when we compare before and during the pandemic. Earlier the focus of teledermatology (TD) was mainly for follow-up care (85%), whereas during the pandemic, both new and follow-up patients were provided virtual consultations. The number of patients coming to them for a consultation has drastically reduced. Only 2% of the responders are still performing minor procedures with proper care. Almost two-thirds do not have systems in place to train their residents and fellows due to the disruptions caused by the pandemic. The rest of them have started to take the virtual route of teaching through webinars, virtual rounds, and providing access to online journals to continue their teaching. Only 18.6% of dermatologists at work were provided with personal protective equipment. TD has opened new doors to virtual consultation and it was evident that 54.4% of doctors are willing to continue it in the future even after the pandemic is over. Conclusion: TD platforms hold great promise to improve access to high-quality dermatologic care in the future. Results from this survey of Indian dermatologists suggest that TD is the future of dermatology as it will be accessed by patients in remote areas and it is a cost-effective move for the patients.
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Patch test results of 276 cases with footwear dermatitis - A retrospective study from a tertiary care centre in South India p. 720
Anoop Thyvalappil, Rajiv Sridharan, MP Amrutha, Gayathri Nair, Ajayakumar Sreenivasan
DOI:10.4103/idoj.IDOJ_560_19  
Background: Allergic contact dermatitis (ACD) is a major cause for foot wear dermatitis. Patch testing is the standard investigation for diagnosis of ACD. Identification of the causative allergen and avoidance of the same is the most important for patient management. Aims: This study was conducted to find the common allergens in footwear, causing ACD, by retrospective analysis of the data of patients who had undergone patch testing with footwear series (FWS), approved by the Contact and Occupational Dermatoses Forum of India. Materials and Methods: A total of 276 cases with footwear dermatitis who underwent patch test with FWS using Finn chamber method were studied. Statistical analysis was done using statistical package for social sciences (SPSS) version 24. Data was described using frequency and percentages. P value of less than 0.05 was considered significant. Results: In this study 101 (36.5%) patients had positive patch test to at least one allergen. Among this, 43 (15.6%) were positive for single allergen only and 58 (21.01%) patients had positive patch test reactions to multiple allergens. The most common allergens with positive patch test were black rubber mix, mercapto benzo thiazole, and thiuram mix. Patients with either a positive or negative patch test had no statistically significant difference in the history of atopy. The limitations of this study include the lack of patch testing with the patient's own footwears and lack of follow-up after informing patients regarding allergen avoidance. Conclusions: Patch test must be done for all foot eczema cases for early identification of the causative allergen and also to provide suitable alternatives.
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Use of topical steroids in dermatology: A questionnaire based study p. 725
Sonali R Karekar, Padmaja A Marathe, Vetrivel Babu Nagarajan, Uday S Khopkar, Siddhi B Chikhalkar, Priyashree K Desai, Minakshi S Dongre
DOI:10.4103/idoj.IDOJ_566_19  
Context: Topical steroids, the most widely prescribed drugs in dermatology are being increasingly misused. Aims: This study was conducted to assess knowledge and practices regarding the use of topical steroids and to analyze prescriptions containing topical steroids. Subjects and Methods: Following approval from the institutional ethics committee, participants were recruited as per the selection criteria and divided into those treated in the institution and those having outside prescription. They were administered a pre-validated questionnaire to assess knowledge and practices regarding the use of topical steroids. Statistical Analysis Used: Comparison of awareness between two patient categories was done using Chi-square test. Prescription variables were analyzed using descriptive statistics. Significance of P value was set at 0.05. Results: Out of 400 patients, 167 had external prescriptions whereas 233 were institutional patients. Only 5.5% of all patients knew about the type of drug prescribed whereas 31.25% were aware of the indication. A total of 33.75% of the patients knew topical steroids required a prescription and 5.6% said they were aware that topical steroid use was associated with side effects. Side effects were reported by 96 patients. Awareness regarding knowledge, indication, and need for prescription were significantly better in institutional patients whereas knowledge about side effects was lacking in both groups. Psoriasis was the most common indication overall whereas tinea was the most common indication (51.5%) among externally prescribed. Conclusions: Although this study showed that institutional patients had comparatively better knowledge than community-treated patients, there is a need to create more awareness among patients overall and implement measures to stop irrational prescribing practices in the community.
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Prevalence of cold dermatoses in kashmir valley: A cross-sectional study from North India p. 731
Faizan Y Shah, Iffat Hassan, Sumaya Zeerak, Shahnawaz Bashir, Yasmeen Jabeen, Shagufta Parveen, Syed Mubashir, Javeed Sultan, Shazia Jeelani
DOI:10.4103/idoj.IDOJ_543_19  
Background: Often quoted as ”heaven on earth,” Kashmir forms one of the two divisions of the Union territory of Jammu and Kashmir. A high-altitude region with abundant precipitation and snowfall, the people of Kashmir experience peculiar dermatoses not commonly seen in the majorly tropical subcontinent of India. In this study, we focussed on cold dermatoses as a comprehensive cluster and attempted to study them as a group. Aims: To determine the prevalence of cold dermatoses in Kashmir valley and study their epidemiological characteristics. Methods: This observational, cross-sectional community-based study was conducted on native Kashmiri population in three districts of the valley, exclusively during the winter season of the year 2016–17 and 2017–18. The data were tabulated and analyzed with Chi-square test for discrete variables and t-test for continuous variables, using OpenEpi. A P value of less than 0.05 was taken as significant. Results: The study included a total of 1200 cases with 602 males and 598 females. Perniosis was most commonly encountered dermatoses in our study with a prevalence of 12.2%. Frostbite had a prevalence of 0.83%. Raynaud's phenomenon and asteatotic eczema were seen in 1.5% and 1.67% of the population, respectively. Cold panniculitis, cold urticaria, and livedo reticularis were each seen in 0.08% of the population. Conclusions: Cold dermatoses form an important source of morbidity among the native population of Kashmir. These can be easily prevented by ensuring adequate protection against cold. Creating awareness regarding these disorders and probable association with connective tissue disorders is also imperative.
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Clinical profile of overgrowth syndromes consistent with PROS (PIK3CA-related overgrowth syndromes)—A case series p. 738
Lydia Mathew, Renu George, Sniya Sudhakar, Shyamkumar N Keshava, NA Fouzia
DOI:10.4103/idoj.IDOJ_520_19  
Context: PIK3CA-related overgrowth syndrome (PROS) is characterized by focal and disproportionate growth of acral body structures in a mosaic pattern with varied phenotypes. Clinical diagnostic criteria are available and testing of the mutation is recommended for diagnosis. Cutaneous features described in these conditions include epidermal nevi and vascular malformations which form part of the diagnostic criteria. Aims: To detail the clinical profile of patients with presumptive PROS. Settings and Design: We conducted a retrospective study of 15 patients with focal overgrowth of the extremities or macrocephaly who presented to the department of dermatology at a tertiary care hospital in South India. Subjects and Methods: Data were collected through electronic medical records from July 2012 to April 2018 over 70 months. The criterion proposed by Keppler-Noreuil et al. was used for classifying them as presumptive PROS in the absence of genetic studies. Statistical Analysis Used: Descriptive analysis. Results: There were nine males and six females; mean age of 12.10 years (range: 8 months to 73 years) with clinical features consistent with PROS. There was a higher frequency of vascular malformations (9/15, 60%) and of epidermal nevi (7/15, 46.6%) than that reported in the literature. Unusual features included focal acrochordons, blaschkoid hypopigmentation and linear papillomatous growths in the oral mucosa. Conclusions: This study provides data on the clinical features of patients with PROS from the Indian subcontinent. In resource-poor settings, clinical criteria may be adequate for diagnosis due to restricted accessibility of technically challenging diagnostic tests.
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Role of tinea unguium and other factors in chronic and recurrent dermatophytosis: A case control study p. 747
Faizan M Kalekhan, Amina Asfiya, Manjunath M Shenoy, B Vishal, Malcolm Pinto, Spandana P Hegde
DOI:10.4103/idoj.IDOJ_515_19  
Context: There is an alarming rise in the incidence of chronic and recurrent dermatophytosis (CRD) in India. Many factors including tinea unguium may be responsible for it. Aims: To evaluate various epidemiological and clinical factors including the presence of tinea unguium as a risk factor for CRD. Settings and Design: This was a case-control study in which patients attending the dermatology outpatient department of a tertiary care hospital in February–March 2019 were recruited. A total of 80 consecutive clinically diagnosed patients with CRD as per the case definition (cases) were selected. Another 80 consecutive patients with dermatophytosis other than CRD (controls) were also selected. Patients were clinically evaluated with special attention for the presence of tinea unguium. Results: Among the total of 80 cases, 44 (55%) and 36 (45%) were diagnosed to have chronic dermatophytosis and recurrent dermatophytosis respectively. CRD was relatively uncommon in patients younger than 20 years. Sharing of linen, family history, and topical corticosteroid abuse were also frequent among patients with CRD. Tinea unguium was present in six cases (7.5%) and two controls (2.5%) which was not statistically significant (P = 0.27). Conclusions: The current epidemic of CRD may be primarily due to a pathogen with certain specific epidemiological and clinical determinants. It may be primarily a skin pathogen with less or no affinity toward the hair and nail.
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BRIEF REPORTS Top

Association of psoriasis with autoimmune disorders: Results of a pilot study p. 753
Sanket Vashist, Vikram K Mahajan, Karaninder S Mehta, Pushpinder S Chauhan, Rajinder S Yadav, Satya Bhushan Sharma, Vikas Sharma, Anuj Sharma, Bhumika Chowdhary, Prabal Kumar
DOI:10.4103/idoj.IDOJ_648_19  
Background: Association of psoriasis with other autoimmune diseases remains an ongoing research subject. Objectives: To investigate the association of psoriasis with other autoimmune disorders. Materials and Methods: We studied 80 (M: F 57:23) psoriasis patients aged 13–75 years for concurrent autoimmune disorders. After clinical examination, hemogram, fasting blood sugar, HbA1c, thyroid function tests, anti-TPO antibody, rheumatoid factor, anti-tTG antibody, anti-CCP antibody, ANA, anti-dsDNA antibody, anti-Ro antibody, and fecal calprotectin were estimated. Results: Mild-to-moderate and severe psoriasis was present in 86.3% and 13.8% patients, respectively. Psoriatic arthritis was present in 3.8% patients, all of whom also had severe psoriasis. Only 37 (46.3%) patients had clinical and/or sero-abnormality suggestive of autoimmune disorders; vitiligo in 3.8%, type-1 diabetes mellitus (DM) in 1.3%, and type-2 DM in 6.3% patients. Sero-positivity reflecting subclinical autoimmunity was noted for anti-CCP antibodies (in 2.5%), rheumatoid factor (in 2.5%), hypo- or hyper-thyroidism (in 8.8%), anti-TPO antibodies (in 5.0%), anti-tTG antibody (in 1.3%), ANA (in 5.0%), anti-dsDNA antibody (in 2.5%), and anti-Ro antibody in 11.3% patients. Elevated fecal calprotectin levels suggestive of inflammatory bowel disease (IBD) occurred in 11.2% of 27 patients. Multiple abnormalities happened in 2.5% patients. Conclusion: Apparently psoriasis patients seem to have a predilection for other autoimmune disorders particularly for vitiligo, diabetes mellitus, autoimmune thyroiditis, rheumatoid arthritis, and IBD. However, association between psoriasis and other autoimmune disorders at best remains tenuous for want of strong evidence. Nevertheless, screening for them will improve overall management of these patients. Cross-sectional study design and small number of study subjects remain important limitations.
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Face and neck pigmentary alterations in hair dye users: A cross-sectional study from South India p. 760
Valeti Meghana, Hima Gopinath, Kaliaperumal Karthikeyan, Vinayagamoorthy Venugopal
DOI:10.4103/idoj.IDOJ_313_19  
Background: Hair dyes are commonly used for the concealment of grey hair in India. The pigmentary alterations produced by hair dyes on the face and neck have not received sufficient attention. Aims: To study the pigmentary alterations on the face and neck in hair dye users, and identify possible risk factors associated with the face and neck hyperpigmentation. Methods: A hospital-based descriptive cross-sectional study was done on consecutive hair dye users. A detailed history was taken, and a clinical examination was done to record the pigmentary alterations. The patterns, areas affected, the intensity of hyperpigmentation, percentage of the area involved and risk factors were noted. Results: One hundred and twenty patients were included in the study. Around 118 (98.3%) patients had hyperpigmentation over face and/or neck: 16 (13.3%) barely perceivable, 40 (33.3%) mild, 44 (36.7%) moderate, and 18 (15%) severe pigmentation. The lateral forehead (106, 88.3%), the helix of the ear (106, 88.3%), central forehead (97, 80.8%), and zygomatic area (92, 76.7%) were the most frequently affected areas in our study. Fourteen patients (11.7%) had depigmented macules on the scalp and/or lips. Conclusion: Pigmentary alterations, particularly hyperpigmentation over the upper face and ears are common with the use of hair dyes. The skin type may play a role in the intensity of hyperpigmentation.
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Assessment of impairment of quality of life in foot eczema and correlation thereof with epidemiological data of its patients: A cross-sectional study p. 766
Prachi V Agrawal, Yugal K Sharma, Ajay Kumar, Mahindra Deora, Aishwarya Raheja, Rajeshri Kharat
DOI:10.4103/idoj.IDOJ_588_19  
Background: Eczema of foot adversely impacts daily activities, work productivity, and interpersonal relationships. Materials and Methods: This cross-sectional, questionnaire-based study collated epidemiological data of 70 outpatients of foot eczema, evaluated their quality of life by 10-item dermatology life quality index (DLQI) questionnaire, and undertook the correlation thereof. Results: Cases were predominantly males (48; 68.5%); 26 (37.1%) belonged to fifth decade of life and 47 (67%) presented within 12 months of onset. Dorsa of feet was involved in most (59; 84.2%) cases. Itching was a universal complaint followed by scaling (51; 72.9%), dryness (22; 31.4%), and oozing (21; 30%). History of atopy was reported by 15 (21.4%) patients; tobacco and/or alcohol abuse 32 (45.7%) patients; past treatment was received by 37 (52.9%) patients; and winter aggravation in 9 (12.3%) patients. Mean DLQI score was 13.64; with very large effect (11–20) on QoL in 38 (54.3%) patients; moderate (6–10) in 15 (21.4%) patients; extremely large (21–30) in 9 (12.9%) patients; and small (2–5) in 8 (11.4%) patients. Mean scores of questions of DLQI tool were 2.46 in first question (symptoms), 1.99 in fifth (social activities); 1.81 in seventh (working/studying); and 0.17 in fourth (clothes) question. Significant (P < 0.05) impairment of quality of life emerged with respect of burning, scaling, oozing, history of atopy, seasonal variation, and past treatment. Conclusion: Our study reports significant association of atopy, winter aggravation, past treatment, burning, scaling, and oozing with adverse quality of life in our study on cases of foot eczema and appears to be first study from India.
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The association of thyroid dysfunction with chronic plaque psoriasis: A hospital-based retrospective descriptive observational study p. 771
Ashwani Rana, Vikram K Mahajan, Pushpinder S Chauhan, Karaninder S Mehta, Satya Bhushan Sharma, Anuj Sharma, Reena Sharma
DOI:10.4103/idoj.IDOJ_432_19  
Background: Associations among thyroid dysfunction, thyroid autoimmunity, and clinical features including age, gender, disease duration, and severity of psoriasis is less studied. Objectives: To study frequency of thyroid dysfunction and thyroid autoimmunity and examine association among thyroid dysfunction, thyroid autoimmunity, and clinical features including gender, age, duration, and severity of psoriasis. Material and Methods: The medical records of 290 (m:f 2.15:1) patients aged 13–75 years with plaque psoriasis were analyzed for thyroid dysfunction and thyroid autoimmunity. Thyroid dysfunction was defined as 10% variation in any thyroid hormone levels. Thyroid autoimmunity was diagnosed from presence of antithyroid peroxide (anti-TPO) antibodies. Results: The majority, 57.9% patients, was aged ≥41 years (Type-2 psoriasis) and duration of disease was <5 years in 58.6% patients. Mild and moderate to severe psoriasis was present in 58.3% and 41.7% patients, respectively. Deranged thyroid functions were present in 29 (10%) patients. Hypothyroidism and hyperthyroidism occurred in 5.4% and 2.7% patients, respectively. Anti-TPO antibodies were observed in 13.5% patients; 11had hypothyroidism. There was no statistically significant difference in gender, age, duration, and severity of psoriasis when compared with patients having normal thyroid function tests. Conclusion: The study suggests possible thyroid dysregulation and thyroid autoimmunity in psoriasis but results need careful interpretation and clinical application. Their significance as standalone risk factor for the chronicity, severity, and relapses in psoriasis or whether thyroid hormone replacement or antithyroid drugs become a useful therapeutic option remains tenuous at best for need of more robust evidence. Retrospective, observational, cross-sectional study design, small number of patients, and lack of controls remain major limitations.
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Dermoscopy of onycholysis due to nail psoriasis, onychomycosis and trauma: A cross sectional study in skin of color p. 777
Balachandra S Ankad, Aakash Gupta, Rallapalli Alekhya, Morlawar Saipriya
DOI:10.4103/idoj.IDOJ_475_19  
Background: Clinical differentiation of onycholysis due to various etiologies is difficult task that compels to do invasive investigations to arrive at accurate diagnosis. Wrong diagnosis often leads to treatment failure and physicians and patient's anxiety. Dermoscopic patterns in nail psoriasis, onychomycosis are well established. Here, authors attempted to describe dermoscopic patterns in onycholysis due to psoriasis, onychomycosis and trauma in skin of color. Methodology: Study was conducted in a tertiary hospital in Southern India. Ethical clearance and informed consent from patients was obtained. Sixty consecutive patients who attended dermatology outpatient department with onycholysis were included in the study. Nail potassium hydroxide (KOH) study was done in all the cases. Onychoscopy was done with DermLite 3 with ultrasound gel as interface medium. Results: Totally 60 patients (42 males; 18 females) with onycholysis were included. Mean age was 37 years (range; 6-68 years). KOH was positive in 22 (36.6%) cases. Onychoscopy showed proximal erythematous rim, red dots, splinter hemorrhages in 23(65.71), 26 (74.28) and 21(60) in nail psoriasis respectively. Spiked and jagged-edges, aurora borealis and ruins pattern (65%) suggestive of onychomycosis were seen in 18(90%), 17 (85%) and 13 (65%) patients respectively. Plain edges without erythema or spikes were noted in 5 (8.33%) in traumatic onycholysis group. Conclusion: Onychoscopy is a non- invasive modality to diagnose psoriasis, onychomycosis and traumatic involvement of nail apparatus by demonstrating characteristic patterns. Hence, it also plays an important role in effective management of such cases.
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Study of BCG immunotherapy in the management of multiple, extensive non-genital cutaneous common warts Highly accessed article p. 784
Angoori Gnaneshwar Rao, Ruhi Haqqani
DOI:10.4103/idoj.IDOJ_461_19  
Background and Aims: Most of the available treatment therapeutic modalities for warts are aimed at destruction of virus. However, despite adequate treatment, the virus may persist in the surrounding tissues leading to recurrence. Owing to side effects such as pain, scarring, and risk of secondary infection, these modalities may not be suitable for multiple lesions, extensive involvement and for the treatment of warts in the paediatric age group. The aim of the study was to evaluate the efficacy and safety of intra lesional BCG vaccine in the management of patients with multiple extensive non-genital common warts. Methods: Thirty patients with multiple, extensive non-genital cutaneous common warts, with age ranging from 6 to 60 years who were not on any treatment for warts and did not have any active infections (including HIV) or past history of tuberculosis attending the department of dermatology of our hospital in a 2-year period were included. Mantoux test was performed in all patients and positive responders were taken up for study. BCG vaccine was administered into the largest wart intradermally and the injection was repeated every 3 weeks for a maximum of five injections or till the complete clearance of warts, whichever was earlier . The efficacy was assessed every 3 weeks and a final assessment was done at the end of the 12th week. Patients were followed up for another 6 months. Observations: Majority of patients were in the age group of 5-14 years. Males (63.3%) were afflicted more than females. Most patients (63.3%) exhibited partial response at the site of injected wart at the end of one month and 70% patients showed complete clearance at the end of 3 months and 36.6% responded with 3 injections and 26.6% patients required 4 for response followed 23.3% requiring 5 injections. Conclusion: Intralesional immunotherapy using by BCG vaccine appears to be is a promising treatment modality for the treatment of warts, particularly the multiple and recalcitrant ones. The advantages include the resolution of both the injected and distant warts with negligible recurrence and with minimal side effects.
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CASE REPORTS Top

Pseudocyst of auricle—An uncommon condition and novel approach for management p. 789
Priya U Agrawal, Krina B Patel, Vasim F Chauhan, Savfeena M Nagani
DOI:10.4103/idoj.IDOJ_532_19  
Pseudocyst of the auricle is a rare benign condition due to the accumulation of intracartilaginous fluid. Various treatment modalities are suggested in literature; the goal being the preservation of architecture of the pinna and prevention of recurrence. We report two cases: An 11-year-old boy treated conventionally with surgical management with the development of mild deformity and an 18-year old male treated with novel nonsurgical modality with the excellent cosmetic result. Here we emphasize the importance of such a simple routine procedure, which can be done on an OPD basis with a better cosmetic outcome.
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Adult-onset asthma with periocular xanthogranuloma (AAPOX), a variant of periorbital xanthogranulomatous disease: An uncommon entity p. 792
Kananbala Sahu, Madhusmita Sethy, Chandra Sekhar Sirka, Arpita Nibedita Rout
DOI:10.4103/idoj.IDOJ_541_19  
Adult orbital xanthogranulomatous disease (AOXGD) is a rare granulomatous disorder. Adult-onset asthma with periocular xanthogranuloma (AAPOX) which is a subtype of AOXGD is very rare and a realtively unknown entity among dermatologists. Very few cases had been reported in literature. Clinically recurrent periorbital swelling and its location may mimic other dermatological conditions like sarcoidosis, necrobiotic xanthogranuloma, dermatomyositis, and rarely amyloidosis. Herein we report a female with recurrent periorbital swelling with brownish yellow papulonodular lesions on periorbital area with adult-onset asthma. Histopathology and immunohistochemistry proved the diagnosis. She was started with systemic methylprednisolone and methotrexate and improved significantly after 4 months. We report this case because of its rarity and to create awareness among dermatologists about this uncommon entity.
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Localized grain-leather plaque in urticaria pigmentosa – An unusual coexistence of dual morphology p. 796
Sanjiv Choudhary, Ankita Srivastava, Deepti Joshi, Santosh Tummudi
DOI:10.4103/idoj.IDOJ_540_19  
Urticaria pigmentosa (UP), the most common variant of cutaneous mastocytosis (CM), is characterized by hyperpigmented, brownish macules and patches, with positive Darier's sign. Diffuse cutaneous mastocytosis (DCM), is a rare variant of CM, characterized by diffuse infiltration of the skin by mast cells (MCs), resulting in a typical grain-leather appearance. Blistering is commonly seen in infants with CM but it is not specific for any variant of CM. Herein, we report a case of a 5-month-old male infant who presented with recurrent bullous lesions and hyperpigmented, brownish patches with intervening normal skin suggestive of UP, as well as a single, localized plaque with grain-leather appearance, thereby exhibiting an interesting dual morphology.
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Griscelli syndrome type 3 with coexistent universal dyschromia—An uncommon association of a rare entity p. 799
Sinu Rose Mathachan, Surabhi Sinha, Purnima Malhotra
DOI:10.4103/idoj.IDOJ_572_19  
Griscelli syndrome type 3 is an autosomal recessive disorder caused by mutations in the melanophilin gene and does not have any mucocutaneous or systemic abnormalities other than a pigmentary dilution of skin and hair. We report a case of an 8-year-old girl who presented with silvery grey hair of scalp, eyebrows, eyelashes, and entire body surface with associated universal dyschromia of the skin. After establishing a definite diagnosis of Griscelli syndrome 3, the prognosis was explained and counseling was given. A review of the literature revealed only 27 cases of Griscelli syndrome type 3 in the English language of which only one case by Batrani et al. has reported an associated dyschromia. We report this case to add to the existing literature on this rare condition and to highlight the coexistence of universal dyschromia with Griscelli syndrome type 3.
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Nonisomorphic and nonisotopic multidermatomal discoid lupus erythematosus – A rare subtype of cutaneous lupus erythematosus p. 804
Sanjiv Choudhary, Ankita Srivastava, Mukesh Sahni, Santosh Tummudi
DOI:10.4103/idoj.IDOJ_617_19  
Discoid lupus erythematosus (DLE) is the most common variant of chronic cutaneous lupus erythematosus. Several cases of Blaschko-linear lupus erythematosus, which is regarded as a distinct subtype of lupus erythematosus, have been reported across the globe. Dermatomal involvement in DLE is rare and that too has been reported in patients of systemic lupus erythematosus at site of healed herpes zoster either as an isomorphic or isotopic phenomenon. Here, we report a case of DLE on account of its unusual morphology, de novo multidermatomal configuration, without previous episode of herpes zoster or trauma.
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MUSINGS, OPINIONS, TIPS AND EXPERIENCES Top

Topical itraconazole formulations: Unscrupulous pharmaceutical companies and lax indian drug regulators endangering a precious drug p. 806
Shyam Bhanushankar Verma, Abir Saraswat, P Narsimha Rao, Sunil Dogra
DOI:10.4103/idoj.IDOJ_659_20  
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Brief technical guide for teleconsultation p. 812
Himel Mondal, Shaikat Mondal
DOI:10.4103/idoj.IDOJ_373_20  
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Burnout: The resident evil — Perspectives from the horses' mouth! p. 816
Pallavi Priyam, Abheek Sil
DOI:10.4103/idoj.IDOJ_262_20  
Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions- (1) feelings of energy depletion or exhaustion, (2) increased mental distance from one's job, or feelings of negativism or cynicism related to one's job and (3) reduced professional efficacy. Any profession where a certain amount of emotional work and empathy are expected renders a person vulnerable to being burned out. Resident doctors, who play the role of a primary care-giver and spend a great deal of time with patients, are most prone to suffer. However, early identification and necessary intervention would go a long way in making the three formative years of a doctor's life more worthwhile.
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CONCISE COMMUNICATIONS Top

Co-existent erythromelanosis follicularis faciei et colli and erythroses pigmentosa mediofacialis in a patient of generalized keratosis pilaris - A rare report in a young female p. 818
Vaishali H Wankhade, Priyanka A Kowe, Mugdha M Kulkarni, Rajesh P Singh
DOI:10.4103/idoj.IDOJ_535_19  
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Pityriasis rosea unilateralis: A rare presentation in two females p. 823
Anuja Yadav, Sarita Sanke, Jyoti Yadav, Ram Chander
DOI:10.4103/idoj.IDOJ_558_19  
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Blaschkoid lichenoid drug eruption due to tenofovir p. 826
RekhaVirath , Manisha Balai, Lalit Kumar Gupta
DOI:10.4103/idoj.IDOJ_492_19  
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Unusual presentation of secondary cutaneous metastasis in a female with breast carcinoma p. 828
Satyendra K Singh, Radhika Raheja, Vijay Kumar, Prasanna K Jha
DOI:10.4103/idoj.IDOJ_530_19  
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Circumscribed area of leukotrichia over plexiform neurofibroma: An important clue or mere coincidence? p. 831
Mukesh K Sahni, Jai Kumar Chaurasia, Suman Patra
DOI:10.4103/idoj.IDOJ_606_19  
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Wood's lamp as an inexpensive, handy tool to diagnose solar urticaria p. 833
Sanjiv Choudhary, Ankita Srivastava
DOI:10.4103/idoj.IDOJ_625_19  
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A real-world analysis of relapse rate and efficacy of a restricted monthly dose of omalizumab in recalcitrant chronic spontaneous urticaria in India p. 835
Kabir Sardana, Niharika Dixit, Pooja Arora
DOI:10.4103/idoj.IDOJ_499_19  
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Dermatological manifestation due to preventive measures used during COVID-19 pandemic p. 838
Sandip Agrawal, Saurabh Jaiswal, Dharmendra B Mishra, Sushil Rathi
DOI:10.4103/idoj.IDOJ_343_20  
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LETTER TO THE EDITORS Top

Localized music box spiny keratoderma: A rare variant p. 842
Mohd Mohtashim, Syed Amin, Mohammad Adil, Hera Tabassum
DOI:10.4103/idoj.IDOJ_510_19  
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Bilateral systematized porokeratotic eccrine ostial and dermal duct nevus p. 844
Isha Gupta, Surabhi Dayal, Sanjay Kumar
DOI:10.4103/idoj.IDOJ_460_19  
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Reversible melanonychia revealing nutritional vitamin-B12 deficiency p. 847
TP Afra, T Muhammed Razmi, Tarun Narang
DOI:10.4103/idoj.IDOJ_13_20  
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Multicentric reticulohistiocytosis: A case with minimal cutaneous features p. 849
Nitu , Anuva Bansal, Bijaylaxmi Sahoo
DOI:10.4103/idoj.IDOJ_595_19  
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Violaceous papules and nodules over the umbilicus: The harbinger of occult intra-abdominal malignancy p. 852
Ravikumar Mudugal, Ranjana Beniwal, Saurabh Singh, Sudeep Khera
DOI:10.4103/idoj.IDOJ_68_20  
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A clinical and radiological follow-up of “Rare case of possible vacuolar degeneration of leprosy in the brain with segmental necrotizing granulomatous neuritis and Horner's syndrome” p. 854
Sukriti Baveja, Sunmeet Sandhu, Deepak Vashisht, Manoj Gopinath
DOI:10.4103/idoj.IDOJ_522_19  
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Nodular post kala-azar dermal leishmaniasis: A report on two cases and brief review of literature p. 856
Piyush Kumar, Anupam Das, Rizwana Barkat
DOI:10.4103/idoj.IDOJ_645_19  
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A critical appraisal of IADVL SIG recommendations during COVID-19 pandemic in dermatology practice p. 859
Brahmaiah Upputuri, Rohan Bhattacharjee, Soni Rathore
DOI:10.4103/idoj.IDOJ_616_20  
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DERMATOLOGY PEARL Top

Using Transparent gridded sheets with pre-marked area zones for faster calculation of scalp area for various purposes p. 861
Bhushan Madke, Sandip Agrawal, Aseem Sharma
DOI:10.4103/idoj.IDOJ_601_19  
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TECHNICAL PEARL Top

Modification of a 32 G needle as an eyepiece pointer for light microscopy p. 863
Sandip Agrawal, Sanober Burzin Daruwalla, Rachita S Dhurat
DOI:10.4103/idoj.IDOJ_586_19  
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SKIN INDIA QUIZ Top

A notorious plaque over the groin p. 864
Bantwal P Baliga, Shricharith Shetty, HL Kishan Prasad, Banavasi S Girisha
DOI:10.4103/idoj.IDOJ_309_19  
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Thick, adherent, asbestos-like and overlapping scales encircling the tufts of hair shafts in a 13-year-old girl Highly accessed article p. 866
Prabal Kumar, Bhumika Chowdhary, Vikram K Mahajan
DOI:10.4103/idoj.IDOJ_278_19  
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CLINICOPATHOLOGICAL CHALLENGE Top

Crusted plaque on pretibial area in an adult male p. 869
Rajsmita Bhattacharjee, Debajyoti Chatterjee, Keshavamurthy Vinay
DOI:10.4103/idoj.IDOJ_336_19  
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HISTORY Top

Adverse drug reactions to adverse drug eruptions: A brief historical account from Hammurabi (c. B.C.1810–1750) to Morrow (A.D.1846 -–1913) p. 872
Amiya K Mukhopadhyay
DOI:10.4103/idoj.IDOJ_228_20  
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THROUGH THE LENS Top

Plasma cell gingivitis p. 874
Sweta Subhadarshani, Jayati Sarangi, Savita Yadav
DOI:10.4103/idoj.IDOJ_394_19  
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THROUGH THE DERMOSCOPES Top

Dermoscopy of lichen scrofulosorum Highly accessed article p. 876
Rubina Jassi, Anuja Yadav, Ram Chander
DOI:10.4103/idoj.IDOJ_191_19  
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Nevus sebaceous on face: Histopathological and dermoscopic correlation Highly accessed article p. 878
Priyadarshini Sahu, Silpi Lakra, Surabhi Dayal
DOI:10.4103/idoj.IDOJ_113_19  
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