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   Table of Contents - Current issue
Coverpage
September-October 2021
Volume 12 | Issue 5
Page Nos. 663-790

Online since Sunday, September 12, 2021

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REVIEW ARTICLE  

Acquired dermal macular hyperpigmentation: An update Highly accessed article p. 663
Keshavamurthy Vinay, Anuradha Bishnoi, Divya Kamat, Debajyoti Chatterjee, Muthu Sendhil Kumaran, Davinder Parsad
DOI:10.4103/idoj.IDOJ_881_20  
Acquired dermal macular hyperpigmentation (ADMH) is an umbrella term that includes disorders clinically characterized by small and large pigmented macules/patches and histopathologically showing an evidence of current or resolved interface dermatitis with pigment incontinence, without clinically significant prior inflammatory phase. The term intends to include diseases previously described in the literature as lichen planus pigmentosus, Riehl's melanosis/pigmented cosmetic dermatitis and ashy dermatosis/erythema dyschromicum perstans. The nomenclature and origin of these disorders have always been a matter of discussion. These disorders share many clinicopathological similarities, are difficult to treat and adversely affect the quality of life. Recent consensus points towards the need for a unifying term to facilitate research and therapeutic trials. This article aims to provide a comprehensive review of the recent advances in ADMH.
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CONSENSUS STATEMENT Top

Systemic management of psoriasis patients in Indian scenario: An expert consensus p. 674
Murlidhar Rajagopalan, Manas Chatterjee, Abhishek De, Sunil Dogra, Satyaki Ganguly, Bikash Ranjan Kar, Nina Madnani, Shekhar Neema, SG Parasramani, Krina Patel, Sushil Tahiliani
DOI:10.4103/idoj.IDOJ_113_21  
Background: Psoriasis is a common inflammatory disease with significant comorbidities, and regardless of its extent, it affects the patients' quality of life. The various modalities of treating psoriasis comprise topical or systemic medications, phototherapy, and an array of biologic agents. There is a lack of Indian recommendations on the management of psoriasis with these different modalities and challenges faced by the clinicians in day-to-day practice. Aim: To develop India-specific consensus for systemic management of patients with moderate-to-severe psoriasis. Method and Results: A panel of dermatology experts, based on the evidence and international recommendations, coupled with their own clinical experience, developed recommendations for systemic management of patients with moderate-to-severe psoriasis. Conclusion: These recommendations are meant to provide guidance in terms of choice of systemic therapies, dosing, effectiveness, and safety. It also addresses clinical challenges that may be experienced during psoriasis management.
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REFLECTIONS ON RESEARCH Top

How to write a case report? p. 683
Anupam Das, Inderpal Singh
DOI:10.4103/2229-5178.325856  
Case report is regarded as one of the first line of evidence in medical science. There have been numerous circumstances, where the initial dissemination (and breakthrough) of scientific knowledge had been done, with the help of case reports. Case report is a particular variety of manuscript that showcases the unusual features and management of a patient. The words of William Osler (Father of modern medicine) “Always note and record the unusual…publish it. Place it on permanent record as a short, concise note. Such communications are always of value,” still hold relevance in today's era. In this article, we shall discuss the keys to draft a case report worthy of publication.
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ORIGINAL ARTICLES Top

An observational study of mucocutaneous manifestations among SARS-CoV-2 patients from three COVID-19 dedicated tertiary care centers p. 687
Alpana Mohta, Achala Mohta, Radhe Shyam Nai, Aakanksha Arora, Suresh Kumar Jain, Alok Mohta, Rajesh Dutt Mehta, Bhikam Chand Ghiya, Vijeta Prasad, Rajesh Khokhar, Rajat Toteja, Gaurav Bha`rgava
DOI:10.4103/idoj.IDOJ_127_21  
Introduction: Ever since the outbreak of COVID-19, the respiratory system has been the chief focus of researches, however, understanding the impact of this disease on the integumentary system is just as essential. Objectives: We aimed at collecting data on any cutaneous manifestation arising in patients with active and recovering COVID-19 infection, or a direct consequence of the infection's treatment, and correlating these findings with systemic disease severity and duration. Materials and Methods: A prospective observational study was conducted in three tertiary care centers from Rajasthan, India, to acquire data of laboratory-confirmed cases of COVID-19 presenting with any mucocutaneous manifestation. Results: Eight predominant patterns of dermatological involvement were seen, namely, maculopapular (14.59%), urticarial (13.17%), perniotic (12.1%), pityriasis rosea (11.74%), acral erythema/edema (10.3%), petechial (4.63%), vesicular (2.49%), and livedo (1.78%). Rare findings included eruptive pseudoangioma, eruptive hypomelanosis, alopecia parvimaculata, geographic tongue, chikungunya-like hyperpigmentation, and nail changes. On correlating these findings with the gradient of the disease, livedo, vasculitis, exfoliation, and erythroderma were associated with severe disease, whereas perniosis and eruptive pseudoangioma were seen in mild illness. Conclusion: We reported a few previously unpublished skin manifestations of COVID-19, namely, geographic tongue, chikungunya-like pigmentation, eruptive hypomelanosis, and alopecia parvimaculata. This study provides a visual description of the muco-cutaneous manifestations of COVID-19 disease which could aid a dermatologist or physician in early diagnosis of this novel infection, especially in a resource-poor setting.
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A cross-sectional study to correlate disease severity in bullous pemphigoid patients with serum levels of autoantibodies against BP180 and BP230 p. 696
Naziya Muhammed, Seema Korgaonkar, Vandana Pradhan, Uday S Khopkar
DOI:10.4103/idoj.IDOJ_813_20  
Context: Enzyme-linked immunosorbent assay (ELISA) for BP 180 and 230 antibodies is commonly done in patients with bullous pemphigoid. We could not find much data regarding the usefulness of this test to predict the disease severity in Indian population. Aims: We studied the correlation of IgG anti BP180 and anti BP230 antibody titer with disease severity and clinical features in bullous pemphigoid. Settings and Design: This cross-sectional study was conducted at a tertiary care center in western India. Materials and Methods: Forty-two clinically diagnosed treatment-naive cases of bullous pemphigoid were enrolled and investigated with skin punch biopsy, IgG anti BP180, and anti BP230 ELISA, direct immunofluorescence, and indirect immunofluorescence tests. Disease severity was assessed by calculating modified Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) score. Thirty patients with a final diagnosis of bullous pemphigoid were included in the statistical analysis. Pearson's correlation coefficient (r) was used to study correlation. Results: The mean ABSIS skin score was 32.81 when both tests were negative, 42.13 when only BP230 was positive, 76.28 when only BP180 was positive, and 78.16 when both were positive. Pearson's correlation coefficient (r) for BP180 and ABSIS skin score was 0.6 (P value: 0.0005), and for BP230 was -0.055 (P value: 0.600). Conclusions: BP antibody titers correlate partially with disease severity. Anti-BP180 antibody is associated with more severe disease. Anti-BP230 antibody titer does not correlate with disease severity.
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Efficacy of NB-UVB in progressive versus non-progressive non-segmental vitiligo: A prospective comparative study p. 701
Saurabh Bhatia, Binod K Khaitan, Vishal Gupta, Sujay Khandpur, Kanika Sahni, Vishnubhatla Sreenivas
DOI:10.4103/idoj.IDOJ_40_21  
Introduction: Narrow-band (NB) ultraviolet B (UVB) phototherapy has been shown to halt disease progression in vitiligo, but whether there is any difference in the response to NB-UVB seen in patients with progressive vitiligo versus non-progressive vitiligo has not been evaluated. Objectives: To evaluate the effect of NB-UVB on progressive versus non-progressive non-segmental vitiligo. Study Design: Prospective observational comparative study. Duration: April 2016-November 2017. Methods: Adult patients having non-segmental vitiligo involving 2-50% body surface area were divided into two subsets; patients developing >5 lesions in the last 1 month or >15 lesions in the last 3 months (progressive vitiligo, Group I) and patients with static disease for the last 6 months (non-progressive vitiligo, Group II). Both groups were treated with NB-UVB for 6 months (26 weeks) cumulatively and its efficacy in halting disease progression, re-pigmentation, side effects and psychosocial impact were evaluated. Results: Nineteen out of 24 patients with progressive vitiligo had arrest of disease progression. Rest five patients developed lesions at a slower pace. Group II had earlier onset of re-pigmentation, while Group I had more NB-UVB fluence (34.73 J/cm2 vs 25.2 J/cm2, P value = 0.034), more time for the fluence to be fixed (P value = 0.001) and more pruritus (P value = 0.001). Conclusions: NB-UVB has the potential to halt disease progression in some patients with progressive vitiligo; but is associated with more total NB-UVB fluence and time taken for fixing it. Progressive vitiligo patients have more pruritus as compared to patients with non-progressive vitiligo.
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Clinicopathological profile of childhood onset cutaneous mastocytosis from a tertiary care center in South India p. 706
Dharshini Sathishkumar, Abyramy Balasundaram, Surya Mary Mathew, Lydia Mathew, Meera Thomas, Poonkuzhali Balasubramanian, Renu George
DOI:10.4103/idoj.IDOJ_924_20  
Background: Mastocytosis is characterized by clonal proliferation of mast cells in various organs and can have isolated cutaneous or systemic involvement. Childhood-onset mastocytosis (COM) is usually cutaneous and regresses spontaneously, while adult-onset mastocytosis (AOM) is often persistent with systemic involvement. There is limited data on COM from India. Objective: To elucidate the clinicopathological profile of COM. Methods: We conducted a retrospective chart review of all the patients with histologically proven COM (≤16 years), presenting over 11 years (January 2009 to December 2019) to the Dermatology Department. We compiled the demographic data, clinical characteristics (morphology, extent, distribution), laboratory investigations, histopathology findings, imaging (ultrasound abdomen), c-KIT mutation results, where available, and other associated abnormalities, and grouped them according to the WHO classification for mastocytosis. Results: Among the 66 patients with COM (M: F–1.6:1), 89.4% had onset before 2 years of age. The subtypes were: maculopapular cutaneous mastocytosis (MPCM: 44, 66.7%); mastocytoma of the skin (MOS: 19, 28.8%); diffuse cutaneous mastocytosis (DCM: 2, 3%) and indolent systemic mastocytosis (ISM: 1, 1.5%). Blistering was observed in 29 (43.9%) and Darier sign was elicited in 47 (71.2%) patients. Serum tryptase was elevated in 9/21 (42.9%) patients, but none had systemic mastocytosis. Three patients had c-KIT mutations (two in exon 8 and one in exon 17). Most patients were managed symptomatically and the patient with ISM improved with imatinib. Conclusion: MPCM is the most common variant of COM and most patients had a disease onset before 2 years. Overall, COM had a good prognosis with rare systemic involvement, mitigating the need for extensive evaluation routinely in children.
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BRIEF REPORTS Top

Clinico-mycological profile of treatment-naïve, chronic, recurrent and steroid-modified dermatophytosis at a tertiary care centre in Eastern India: An institution-based cross-sectionalstudy p. 714
Indraneel Saha, Indrashis Podder, SN Chowdhury, Susmita Bhattacharya
DOI:10.4103/idoj.IDOJ_909_20  
Background: Dermatophytosis has recently emerged as a major public health problem in the Indian subcontinent, most cases becoming chronic and recurrent. Aims: Assessing the clinico-epidemiologic and mycologic profile of treatment naïve, chronic, recurrent and steroid-modified dermatophytosis. Materials and Methods: We conducted across-sectional study involving 111 cases of dermatophytosis. Detailed epidemiology, clinical parameters, treatment history and other host factors were assessed along with scraping for potassium hydroxide (KOH) and fungal culture. Results: Among 111 patients,(F: M 1.7:1; mean age 44.4 ± 18.2 years), 51.4% were treatment naïve, while 34.2% and 14.4% presented with chronic and recurrent tinea respectively. Family history and sharing of fomites among infected family members was commoner in the latter groups (P = 0.001). Topical steroid application was reported in 49.5%, however only 7.2% presented with steroid modified tinea. Tinea corporis et cruris (41.4%) was the predominant clinical type followed by tinea corporis (34.2%) and tinea cruris (27.9%). KOH mount and culture were positive in 62.2% and 39.6% cases respectively; commonest isolates being Trichophyton rubrum, and Trichophyton mentagrophytes complex in 15.3% cases each. Trichophyton rubrum was the commonest etiology for treatment naïve and recurrent cases, while Trichophyton mentagrophytes was the commonest isolate from chronic and steroid-modified cases (P = 0.0003). Interestingly, T.mentagrophytes complex and T. rubrum were the commonest causes of tinea corporis and tinea cruris respectively (P = 0.07). Conclusion: Trichophyton rubrum was the commonest organism in treatment naïve and recurrent cases, while Trichophyton mentagrophytes complex accounted for most cases of chronic and steroid modified tinea. The difference in predominant species seems to be a major contributory factor for chronicity and recurrence. However, several host factors like topical steroid use and sharing of fomites also play additional roles.
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Autoimmune diseases, end organ dysfunction and adverse drug reaction following Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): A retrospective cohort study p. 722
Sarita Sasidharanpillai, Amala Theresa Joseph, Kidangazhiathmana Ajithkumar, Keerankulangara Devi
DOI:10.4103/idoj.IDOJ_786_20  
Context: Autoimmune diseases, organ dysfunction and new drug allergies are mentioned as long-term complications after DRESS. There is scarcity of data on this from the country. Aims: To determine the frequency of autoimmune diseases, organ dysfunction, and new drug allergies after the resolution of DRESS. Settings and Design: This retrospective cohort study was carried out among patients who received treatment for DRESS in a tertiary referral center. Materials and Methods: In this retrospective cohort study, DRESS patients who received inpatient care in the dermatology department of our tertiary referral center from August 2014 to February 2017 were included. We excluded patients aged 12 years or below and those who had not completed minimum two years after the resolution of DRESS as on December 2019. We collected information on new onset autoimmune disease, end organ damage and new drug allergies detected after the resolution of DRESS through a telephonic interview. Those who consented were evaluated in our department. Results: We could contact 40/50 (80%) identified individuals and all of them consented for telephonic interview. 17 patients gave consent for revaluation in our department. There were 22 females and 18 males. 17 had definite and 23 had probable DRESS. The frequency of detection of a new disease and a new drug allergy after DRESS was 10% (4/40) and 7.5% (3/40), respectively. We noted three (7.5%) autoimmune diseases (rheumatoid arthritis 1, alopecia areata 1, chronic autoimmune urticaria 1) and one end organ damage (chronic kidney disease) among the study participants. Limitations: Small sample size and retrospective study design were the limitations. Conclusions: Prospective studies with large sample size are needed to delineate the link between DRESS and autoimmunity, end organ damage, and new drug allergies.
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Causal relationship between D-dimers and disease status in chronic spontaneous urticaria and adjuvant effect of oral tranexamic acid p. 726
Garima Dabas, Vishal Thakur, Anuradha Bishnoi, Davinder Parsad, Ashok Kumar, Muthu Sendhil Kumaran
DOI:10.4103/idoj.IDOJ_106_21  
Introduction: Besides autoimmunity, recent studies have reported a role of the coagulation cascade in the pathogenesis of urticaria. However, the real-world data regarding the utility of measuring D-dimer levels in patients chronic spontaneous urticaria (CSU) is missing. This study was done to evaluate the D-dimer levels of CSU patients and study the relationship between raised D-dimer levels and disease severity and treatment response. Methods: A retrospective chart review of all adult (>18 years) CSU patients was done. Complete clinicodemographic data regarding the disease duration and treatment response were noted. Urticaria activity score over 7 days (UAS7) was used to assess disease severity. Results: Of total 141 patients, D-dimer levels were raised in 46 CSU patients (32.6%) with mean D-dimer levels at baseline in these patients being 329.53 ± 546.94 ng/ml. The proportion of patients with raised plasma D-dimer levels was higher in patients with severe CSU (12.9%, 27.2%, 54.5% in mild, moderate, and severe disease, respectively P < 0.001). No significant differences were found between those with raised D-dimers and those having normal D-dimer levels with respect to age, gender, presence of angioedema, history of atopy, presence of thyroid abnormality, ASST/APST positivity, and serum IgE. Conclusion: D-dimer levels parallels the disease severity and can help predict the need for higher dose of antihistamines and second-line therapy in CSU patients.
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A study of clinical, dermoscopic and histopathological correlation in follicular keratotic diseases: Preliminary observations in 30 cases p. 731
Meghana Gangadhar, Keshavmurthy A Adya, Arun C Inamadar
DOI:10.4103/idoj.IDOJ_96_21  
Context: Follicular keratotic disorder is an abnormal keratinization affecting the follicular orifices and clinically characterized by hyperkeratotic follicular papules affecting various sites. Dermoscopy is a non-invasive diagnostic tool and differentiates closely resembling diseases as well as possibly prevents need for an invasive biopsy. Aim: This study was aimed to find the correlation between clinical, dermoscopic and histopathological findings in follicular keratotic diseases and to establish the dermoscopic criteria in the diagnosis of primary follicular keratotic diseases. Materials and Methods: This was a hospital-based prospective cross-sectional study of 30 consecutive patients clinically diagnosed with follicular keratotic diseases, irrespective of age and duration of the disease. Results: The study consisted of 30 patients with a mean age of 19.57 ± 9.69 years. The most common primary follicular keratotic disease observed was phrynoderma and secondary follicular keratotic disease was follicular lichen planus (lichen planopilaris). The predominant dermoscopic finding among all the follicular keratotic diseases was perifollicular scaling 29 (96.7%) followed by keratotic plug 28 (93.3%). The most common histopathological feature was dilated follicular infundibulum 22 (73.3%) followed by follicular plug 15 (50%) and dermal perivascular infiltration 22 (73.3%). The clinical and dermoscopic features showed a significant statistical association with the histopathological findings. Conclusion: Dermoscopy is a simple, non-invasive diagnostic tool that helps in differentiating and diagnosing the closely resembling follicular keratotic diseases.
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CASE REPORTS Top

Dermato-pathologic clues to diagnosis of adult onset still disease: A case report p. 741
Tummidi Santosh, Suman Patra, Garima Goel, Richa Rupla
DOI:10.4103/idoj.IDOJ_383_20  
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory condition classically consists of high spikes of fever, morbilliform evanescent skin rash, arthritis, neutrophilic leukocytosis, and multiple organ involvement. However, atypical form of skin rashes has been described with few specific clinical and histopathological patterns that can help in making the diagnosis. A 25-year-old female presented with high spikes of fever, severe debilitating arthritis of peripheral joints, and dusky erythematous flagellate rashes over trunk and proximal limbs. Skin punch biopsy from the cutaneous lesion revealed dyskeratotic keratinocytes in upper epidermis and stratum corneum along with acute inflammatory infiltrate in the dermis: a finding that recently has been found to be constantly associated with this specific pattern of rash of AOSD. The presence of necrotic keratinocytes in upper epidermis and a dermal infiltrate of neutrophils along with characteristic clinical scenario may facilitate earlier diagnosis of AOSD.
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A rare case report of bcg induced balanitis in a patient with transitional cell carcinoma of urinary bladder p. 745
Debdeep Mitra, Anuj Bhatnagar, Devinder Suhag, Sunmeet Sandhu
DOI:10.4103/idoj.IDOJ_158_21  
Primary Bacillus Calmette–Guérin (BCG) infection of the glans penis is not a very common entity and has been rarely reported in literature. BCG has been used as an adjuvant therapy in patients of transitional cell urinary bladder carcinoma following transurethral resection of bladder tumor. We report a 66-year-old male patient who was being managed for urinary bladder carcinoma with nine sittings of adjuvant BCG therapy. He developed painless swelling with multiple pustules over glans penis and prepuce along with inguinal lymphadenopathy. He had a BCG inoculation scar over his arm and his chest X-ray was within normal limits. His workup for sexually transmitted disease was negative. The biopsy from the nodule on prepuce revealed mixed inflammatory infiltrate comprising of neutrophils, lymphocytes, and eosinophils along with numerous congested blood vessels and hemosiderin macrophages. Mycobacterium tuberculosis gene expert from tissue was positive for acid fast bacilli (AFB). Fine-needle aspiration cytology from the right inguinal lymph node also revealed AFB on Ziehl–Neelsen stain. The BCG immunotherapy was stopped and the patient was started on a standard four-drug antitubercular therapy comprising isoniazid, rifampicin, ethambutol, and pyrazinamide along with daily doses of pyridoxine. The edema resolved and papules subsided within 2 weeks after starting antitubercular therapy. This is a very rare presentation although intravesical BCG therapy is a very common treatment modality, hence this report is intended to increase awareness of this condition in dermatologists and venereologists.
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CONCISE COMMUNICATIONS Top

Clinical and dermoscopic features of follicular Becker's nevus: A rare variant p. 750
Harshal Ranglani, Subrata Malakar
DOI:10.4103/idoj.IDOJ_877_20  
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Accidental ocular injury by topical dermatological agent: Potassium permanganate (KMnO4) p. 752
Renu Kandpal, Subhash Gautam
DOI:10.4103/idoj.IDOJ_935_20  
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Subacute cutaneous lupus erythematosus: Diagnosis and follow up by dermoscopy p. 755
Biswanath Behera, Ashish K Nayak, Siddharth Dash, Madhusmita Sethy
DOI:10.4103/idoj.IDOJ_906_20  
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Trachyonychia with juvenile pityriasis rubra pilaris p. 758
Chander Grover, Geetali Kharghoria
DOI:10.4103/idoj.IDOJ_840_20  
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Yoga sign-A locus minoris resistentiae to remember p. 760
Shyam Bhanushankar Verma, Uwe Wollina
DOI:10.4103/idoj.IDOJ_918_20  
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Pearls for dermatology residency p. 762
Namrata Chhabra, Hanish Sharma
DOI:10.4103/idoj.IDOJ_800_20  
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The adverse cutaneous effects of hand hygiene practices among individuals other than non-healthcare providers during coronavirus-19 pandemic: A cross-sectional online survey p. 765
R Jindal, P Chauhan, YS Bisht, S Roy
DOI:10.4103/idoj.IDOJ_773_20  
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Urticaria multiforme post pneumococcal vaccination in an infant p. 768
Sree R Suggu, Venkata C Konakanchi, Ajay K Gummalla
DOI:10.4103/idoj.IDOJ_709_20  
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LETTERS TO THE EDITOR Top

Turban tribulations: Triad of turban ear, traction alopecia, and traumatic acne in a sikh patient p. 770
Hitaishi Mehta, Sheetanshu Kumar, Anuradha Bishnoi
DOI:10.4103/idoj.IDOJ_798_20  
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A curious case of drug-induced subacute cutaneous lupus erythematosus p. 772
Anupama Bains, S Varun Rajagopal, Deepak Vedant, Poonam Elhence
DOI:10.4103/idoj.IDOJ_864_20  
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Achenbach syndrome: A rare case of paroxysmal finger hematoma p. 774
Vishal Gaurav, Chander Grover
DOI:10.4103/idoj.IDOJ_822_20  
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Multifocal cutaneous sarcoidosis presenting as lid ectropion p. 776
Divya Kamat, Vinod Hanumanthu, Divya Aggarwal, Tarun Narang
DOI:10.4103/idoj.IDOJ_687_20  
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DERMATOLOGY PEARLS Top

An innovative treatment for grade 1 stage of ingrown fingernail Highly accessed article p. 778
Muhammed Mukhtar
DOI:10.4103/idoj.IDOJ_763_20  
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SKINDIA QUIZ Top

A flat-topped plaque over the mammary area p. 780
Biswanath Behera, Laxmisha Chandrasekhar, Devinder Mohan Thappa, Debasis Gochhait
DOI:10.4103/idoj.IDOJ_797_20  
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THROUGH THE LENS Top

Anterior cervical hypertrichosis p. 783
Piyush Kumar, Anupam Das
DOI:10.4103/idoj.IDOJ_416_20  
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Avian mite dermatitis: A diagnostic challenge p. 784
Shrikant Kumavat
DOI:10.4103/idoj.IDOJ_377_20  
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Anagen effluvium: A trichoscopic analysis Highly accessed article p. 786
Savera Gupta, Sujay Khandpur, Neetu Bhari
DOI:10.4103/idoj.IDOJ_18_20  
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An itchy rash over a foot: Dermoscopy clinched the diagnosis Highly accessed article p. 788
Pooja Gupta, Dinesh P Asati, Suman Patra
DOI:10.4103/idoj.IDOJ_34_20  
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NOTICE OF RETRACTION Top

Retraction: Comparative analysis of BIOCHIP mosaic-based indirect immunofluorescence with direct immunofluorescence in diagnosis of autoimmune bullous diseases: A cross-sectional study p. 790

DOI:10.4103/2229-5178.325862  
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