Cutaneous and genital warts are common dermatological conditions caused by the human papilloma virus (HPV). Although it is a benign condition, it causes disfigurement, has a tendency to koebnerize, and can be transmitted to others. This makes adequate and timely treatment important. There are several conventional treatments available with variable response. Topical and systemic immunotherapy has now found a significant place in the treatment of warts because of its nondestructive action, ease of use, and promising results. Through this review, we would like to present a brief overview of the various immunotherapeutic agents used. These include more established agents such as imiquimod, Mycobacterium w vaccine, bacillus Calmette-Guérin vaccine, measles, mumps, and rubella vaccine, Candida antigen, trichophyton antigen, tuberculin, zinc, cimetidine, levamisole, HPV vaccine, and autoimplantation therapy. Other agents such as contact immunotherapy which is sparsely used now than before and newer agents such as Corynebacterium parvum, sinecatechins, echinacea, propolis, glycyrrizinic acid, and Vitamin D have also been discussed. The mechanism of action of these agents, along with their dosage, mode of administration, duration of use, expected outcomes and comparative efficacy, evidence for their use, and expected side effects, if any, are reviewed.

Background: Alopecia areata (AA) is a common, recurrent, autoimmune hair disorder. It has been found that vitamin D deficiency is associated with many autoimmune diseases. Aims: The current study aimed to estimate serum levels of 25-hydroxy vitamin D in patients with AA. Materials and Methods: This case–control study included 60 patients with AA and 60 age, gender, skin phototype, and body mass index-matched healthy subjects as a control group. Levels of serum 25-hydroxy vitamin D were estimated using ELISA technique. Results: Serum 25-hydroxy vitamin D levels were significantly lower in AA cases when compared with healthy controls (P < 0.001). The least values were significantly associated with alopecia totalis/universalis compared with patchy AA (P< 0.001) and ophiasis (P = 0.04). Severe AA showed significantly the lowest vitamin D levels compared with cases with mild (P = 0.002) and moderate disease (P = 0.03). A significant inverse correlation was found between 25-hydroxy vitamin D levels and age of the patients (r = −0.38; P = 0.03). There was no significant association between serum 25-hydroxy vitamin D levels and gender, disease duration, disease recurrence, nail affection, duration of sun exposure/day, or positive family history of AA. Conclusion: AA patients have lower levels of 25-hydroxy vitamin D than healthy subjects. More studies are required to assess the value of vitamin D supplementation in the treatment of that disease.

Background: Oral isotretinoin is highly effective in all forms and grades of acne, even in lower dosages (<0.5 mg/kg/day). There is a paucity of comparative data on the various low-dose regimens of oral isotretinoin in the Indian literature. Objectives: To assess and compare the efficacy and tolerability of two low-dose oral isotretinoin treatment regimens (20 mg daily and 20 mg alternate days) in moderate to severe acne vulgaris. Materials and Methods: A total of 240 patients with moderate to severe acne vulgaris were selected and randomized into two groups and treated with a fixed dose of 20 mg of isotretinoin (Group A - daily and Group B - alternate days) for 24 weeks and followed up for 12 weeks post therapy. Results: A total of 234 patients completed the study. At the end of therapy, decrease in the total acne loads up to 98.99% (Group A) and 97.69% (Group B) was achieved from the baseline (P < 0.01), excellent response was observed in 98.3% (Group A) and 93.96% (Group B) patients (P = 0.166). In the severe acne, Group A performed significantly better than Group B until the end of 36 weeks. While in the moderate acne, significant difference in the response between both groups was observed only up to 12 weeks. No serious side effect was observed. Conclusion: Both isotretinoin regimens were well tolerated and found to be an effective treatment for moderate to severe acne vulgaris. However, in moderate acne 20 mg alternate day regimen may be preferred. A 20 mg daily regimen is a better choice for severe acne in terms of response. Limitation: Small sample size and short follow-up period.

Eosinophilic fasciitis, also known as Shulman's syndrome, is a fibrosing scleroderma-like syndrome, which is a distinct entity. A 55-year-old man, presented with progressive skin darkening, thickening, and tightening over the left lower limb since 6 months. Dermatological examination revealed a hyperpigmented indurated area on the left thigh, extending to the anterior aspect of the left leg. A well-defined hypopigmented indurated plaque was present over the left iliac region. Histopathology and imaging studies confirmed the diagnosis of eosinophilic fasciitis and lichen sclerosus. The indurated lesion on the left lower limb responded dramatically well to oral corticosteroids. This is a rare case of unilateral eosinophilic fasciitis associated with ipsilateral extragenital lichen sclerosus.

Granular cell tumors (GCTs) are uncommon soft tissue tumors which present as papulonodular lesions and are often diagnosed histopathologically. These usually develop in adulthood and are considered to be of Schwann cell origin. Most of the lesions are benign, but malignant lesions with poor prognosis are known to occur. We report a case of GCT in a 9-year-old girl presenting as an isolated lesion simulating an acrochordon. The histopathological and immunohistochemical evaluation showing polygonal granular cells positive for S-100 and neuron-specific enolase, and negative for cytokeratin and desmin helped clinch the diagnosis. Complete excision under local anesthesia was done. The atypical clinical morphology and diagnostic histopathology of this uncommon entity are presented to aid the clinician in recognizing it. These tumors are mostly benign, rarely malignant, with the latter category having a poor prognosis. A near-complete excision is recommended in view of the minimal risk of malignant transformation.

Christ–Siemens–Touraine syndrome is a form of anhidrotic ectodermal dysplasia (ED) characterized by triad of hypodontia, hypotrichosis, and hypohidrosis. Palmoplantar keratoderma is a characteristic feature of hidrotic forms of ED. Till date, only two cases have been reported of Christ–Siemens–Touraine syndrome with palmoplantar keratoderma; here we report a similar case emphasizing this rare association.

Cardiofacio-cutaneous syndrome is a rare genodermatoses with multiple congenital anomalies (MCA) and mental retardation. Although various mutations have been described, the diagnosis can be made clinically based on constellation of symptoms. Herein, we report a classical case with typical craniofacial features and atrial septal defect.

Eosinophilic pustular folliculitis or Ofuji's disease is a non-infectious eosinophilic infiltration of hair follicles, which usually presents with itchy papules and pustules in a circinate configuration. We report this case of an immunocompetent patient with erythematous papules and plaques without macropustules diagnosed as eosinophilic pustular folliculitis—a rarely reported entity outside Japan. He was successfully treated with oral dapsone.

Actinomycosis is a chronic suppurative granulomatous infection of subcutaneous tissues caused by bacterium Actinomyces israelii. It is a normal commensal of the oral cavity, gastrointestinal tract, respiratory tract, and vagina. Infection is first established locally by breach of mucosal barrier during various procedures, aspiration, trauma, or human bite. Rarely, it may spread through hematogenous and lymphatic system. We present a case of actinomycosis involving the vulva, extending to the inguinal region along with inguinal lymphadenopathy. Involvement of vulva by actinomycosis is uncommon in literature.

Lucio phenomenon (LP) or erythema necroticans is a rare type of reaction pattern found in untreated patients with diffuse non-nodular leprosy. It is important to distinguish this from vasculonecrotic erythema nodosum because thalidomide with high-dose steroids is the mainstay of treatment for the latter, whereas LP shows no response to thalidomide. We report a case of a 60-year-old man who presented with purpuric patches, hemorrhagic blisters, and ulcers over extremities of 15 days duration. On cutaneous examination, there were multiple stellate purpuric patches, hemorrhagic bullae, and deep necrotic ulcers, mainly over extremities. Slit-skin smear examination from six sites revealed bacteriological index 6+ with globi, and morphological index 5%. Histopathology revealed diffuse infiltration of bacilli in epidermis, dermis, and endothelial cells along with neutrophilic and lymphocytic infiltrate. Fibrinoid necrosis and thrombosis of blood vessels was also noted. The above clinicohistopathological features helped in making the diagnosis of LP. Concomitantly he was found to be infected with hepatitis C virus. Many triggering factors have been described in literature; however, activation of hepatitis C as a trigger for Lucio phenomenon has not been reported. In addition, IgM and IgG anticardiolipin antibodies were found to be positive. The patient was started on high-dose steroids along with multibacillary antileprosy therapy and improved within 2 weeks.

An 8-year-old girl presented with a scalp swelling. The swelling was recurrent, reappearing everytime after local excision. She underwent surgery and the histopathologic diagnosis was malignant hidradenoma. This very rare and aggressive tumor is known to occur in elderly population and is histopathologically distinct from its commonly occuring benign counterpart. Malignant hidradenoma is resistant to chemotherapy and radiotherapy. We empahsize that being cognizant of the possibility of this rare tumor would assist in timely action in the form of wide resection, with possible reduction in morbidity and mortality.

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), a rare inflammatory disorder, is an association of distinct skin disorders with pustules with osteoarticular inflammation. Its etiology remains unclear, and various treatment regimens frequently fail to control the disease. An 18-year-old male patient presented to the outpatient department with severe nodulocystic acne on the face with pain at both the wrists and lower back associated with high-grade fever and chills. On physical examination, he had severe tenderness at both wrist joints and lower back, along with swelling of right wrist. Magnetic resonance imaging revealed osteitis of the distal end of the right radius. Technetium-99m-MDP Whole Body Bone Scan revealed increased metaphyseal uptake in distal radius on both sides and prominent uptake at the sacroiliac joints, vertebral end plate, left 7^th costo-vertebral joint and bilateral sternoclavicular joints and manubrium sternum (resulting in “bull's head” sign, which is characteristic of SAPHO syndrome). He responded very well to a combination therapy of nonsteroid anti-inflammatory drugs, antibiotics, colchicine, and isotretinoin over a 12-week period.

Methotrexate forms one of the main drugs in the pharmacological management of rheumatoid arthritis, psoriasis, and some neoplastic diseases. Methotrexate rarely causes cutaneous ulceration and most cases are reported in patients with psoriasis and have been accompanied by pancytopenia. The author here reports occurrence of multiple (two) cutaneous ulcers due to methotrexate in a nonpsoriatic patient. The patient was on methotrexate for seronegative rheumatoid arthritis for 10 years. To the best of the Author's knowledge, this is a rare case of cutaneous ulceration due to methotrexate in a nonpsoriatic patient reported in the literature so far, and probably one of its kind without pancytopenia or other hematological abnormalities. Stopping this medication led to complete healing of the ulcerated lesion in about four to six weeks.

This paper describes various less-known clinical signs observed either on clinical examination and investigations in the subject of dermatology.