Nail biopsy is a procedure not routinely resorted to; but when indicated, it is often the only clue left for diagnosis. At such times, it pays to be conversant with it. It is an investigation that not only provides etiologic, diagnostic, and prognostic information but also aids in understanding the pathogenesis of nail diseases. It can be of therapeutic value, especially with respect to nail tumors. This article compiles the procedural techniques for nail biopsy of various types and attempts to summarize the evidence available in the literature. The objective of nail biopsy is to clinch a precise diagnosis of nail pathology with a simple and safe surgical procedure, avoiding pain or permanent nail damage. Patient selection is of utmost importance, wherein, the patient does not have typical skin lesions, yields inadequate information on routine nail investigations, and has no peripheral vascular compromise. The patient needs to be explained about the risks associated, the expected functional handicap, the time required for regrowth, a possibility of permanent nail dystrophy, and a possibility of not achieving a diagnosis even after the biopsy. Techniques and types of various nail biopsies are being discussed in this article. The specimen could be collected as an excision biopsy, punch biopsy, shave biopsy, or longitudinal biopsy. The trick lies in choosing the appropriate area for biopsy. Various biopsy types discussed in this article include nail plate biopsy (easiest and least scarring); nail bed biopsy (elliptical excision or punch); nail matrix biopsy (elliptical excision, punch excision (≤3 mm) or tangential/shave excision); and nail fold biopsy. Complications reported along with means to minimize them are also discussed.

Background: Onychomycosis is a very common disease and accounts for upto 50% of the diseases affecting the nail apparatus. Diagnosis of onychomycosis is usually confirmed with the help of a potassium hydroxide (KOH) mount and fungal culture. Onychoscopy can be a handy and additional tool for the diagnosis. Aims and Objectives: To determine the dermoscopic findings in distal lateral subungual onychomycosis (DLSO). Materials and Methods: A prospective study of 60 nails with a clinical and mycological diagnosis (KOH with Chicago sky blue positive) of DLSO. Dermoscopic examination was performed using a Heine delta 20 plus dermatoscope and the features were recorded. Results: Longitudinal striae and jagged proximal edges seen in all 60 (100%) patients. Intermittent spiked pattern was seen in 47 nails (78.3%). Chromonychia and distal irregular termination were noticed in 23 (38.3%) and 7 (11.7%) nails, respectively. Conclusions: Onychoscopy can be used as an important diagnostic tool while evaluating nail disease, especially in DLSO. Limitations: Small study sample and lack of comparison with other nail diseases that manifests with distal onycholysis.

Background: Chronic kidney disease (CKD)-associated mucocutaneous manifestations significantly impair the quality of life but often remain understudied. They may also vary across regions, socioeconomic and nutritional status, and racial differences. Objectives: To study the patterns of mucocutaneous disorders and their prevalence in CKD patients irrespective of clinical stage or dialysis status. Materials and Methods: 122 (M:F = 77:45) patients aged 21‒85 (Mean ± SD = 57.5 ± 14.0) years having CKD for 3 month to 5 years were studied for mucocutaneous manifestations. Fifty (41%) patients were on hemodialysis for 1‒42 months. Detailed medical history, clinical and mucocutaneous examination, and lab investigations were performed. KOH mounts, skin biopsy, Gram's and Giemsa staining, bacterial or fungal cultures were performed as required. Results: Xerosis in 93 (76.2%), skin pallor in 61 (50%), pruritus in 57 (46.7%), pigmentation in 47 (38.5%), and purpura in 18 (14.8%) patients were the major dermatoses. Bullous lesions and perforating folliculitis occurred in 3 (2.5%) patients each. Major nail abnormalities were pallor (in 35.2%), absent lunula (in 23.8%), nail discoloration (in 18%), and “half-and-half nails” in 16.4% patients, respectively. Hair abnormalities included sparse scalp and body hairs (in 35.2% and 13.1%, respectively) and lusterless hair in 12.3% patients. Coated tongue (in 14.8%), xerostomia (in 12.3%), and macroglossia with teeth indention (in 7.4%) patients were the mucosal manifestations. Conclusions: Xerosis, pruritus, skin pallor/pigmentary changes, nail pallor, absent lunula, nail discoloration, sparse hairs, coated tongue, xerostomia, macroglossia, and infections were the most common mucocutaneous manifestations in the studied patients irrespective of hemodialysis status. Cold and dry climates might be additional aggravators for xerosis/pruritus. Lifelong follow-up may be needed to reduce the morbidity associated with CKD/hemodialysis specific dermatoses appearing over a period.

Background: Psoriasis is one of the most common skin disorders with a prevalence rate of 0.1%–3%. Chronic nature, frequent relapses, absence of permanent cure, and the cosmetic disfigurement of psoriasis have a negative impact on quality of life (QoL) by causing psychological stress. Patients with psoriasis often have unambiguous ideas about the causes, controllability, consequences, and expected time-course of their disease. Aim: The aim of this study is to assess the effectiveness of a video-assisted teaching program regarding psoriasis on the level of knowledge and relaxation therapy on QoL among patients with psoriasis. Materials and Methods: Experimental design was adapted. One hundred and four participants diagnosed with psoriasis were randomly allocated either to an experimental or to a control group. Fifty-two participants were included in each group by simple random sampling. A video-assisted teaching program on psoriasis and relaxation exercises was taught to the participants over a period of 3 months. The tools used were: Psoriasis Knowledge Assessment Questionnaire, modified psoriasis disability index, and modified psoriasis life stress inventory. Results: In the experimental group, the knowledge score was increased significantly from 9 ± 2.2 at baseline to 23.6 ± 1.5 after the intervention. The disability score was decreased from 15.6 to 9.9 and the stress score related to the illness was decreased from 22.8 to 16.9 after the intervention. Conclusion: Educational intervention about disease process and relaxation exercises was effective in improving the knowledge and QoL of patients with psoriasis.

Background and Aims: Multidrug therapy (MDT) in leprosy has brought the prevalence of leprosy to elimination levels. However, these drugs are not without toxicity. The primary aim of this study was to find the prevalence of adverse drug reactions (ADR) to MDT and the secondary aim to study the clinical features of these drug reactions. Materials and Methods: This is a19-year retrospective descriptive study of all new leprosy cases with ADR to MDT, requiring a change in regime. Results: There were 901 new leprosy cases in the study period. There were 28 cases of documented ADR to MDT necessitating a change in regime, thus accounting for a prevalence of 3.11%. There were 24 males (85.71%) and 4 females (14.29%) with a male/female ratio 6:1. Mean age was 39.58 years. Borderline tuberculoid was the commonest type of leprosy in which ADR were seen (46.43%). Dapsone was the commonest drug to cause ADR seen in 17 cases (60.71%). Hepatic involvement in the form of drug-induced hepatitis was the commonest presentation of ADR in this study accounting for 13 cases (46.43%), followed by skin rash, 9 cases (32.14%). There were no ADR reported to clofazimine. No ADR was reported to the alternative regimes given. Conclusions: The prevalence of ADRs was low in this study, with dapsone being the commonest drug. There were no adverse reactions to clofazimine. No adverse reactions were reported with the alternative regimes of ofloxacin and minocycline.

Lipomatosis is characterized by diffuse infiltration of adipocytes in a tissue. A young male patient presented for evaluation of unilateral limb swelling. On evaluation, he was found to have tuberous sclerosis complex with diffuse lipomatosis of the right leg. To the best of the authors' literature search, only two previous reports of association of tuberous sclerosis complex with diffuse lipomatosis were found. The molecular mechanisms behind the co-occurrence of these two entities have not been studied in detail. Abnormalities in lipolysis and lipogenesis pathway may underlie the co-occurrence of tuberous sclerosis complex and diffuse lipomatosis.

To present and discuss a novel association between branch duct-type intraductal papillary mucinous neoplasm and paraneoplastic parapsoriasis. We present the case of a middle-aged male presenting with skin lesions that were suggestive of parapsoriasis, resistant to treatment, and in whom a diagnosis of branch-type intraductal papillary mucinous neoplasm of the pancreas was eventually made. A curative Whipple's surgery led to complete resolution of the skin lesions within 3 weeks. Paraneoplastic parapsoriasis in association with intraductal papillary mucinous pancreatic neoplasm has never been reported before.

Acquired cutis laxa (ACL) is a rare connective tissue disorder characterized by pendulous and coarsely wrinkled skin. There have been few cases of its association to monoclonal immunoglobulin deposition disease (MIDD), which constitutes the light chain (LCDD), heavy chain (HCDD), and light and heavy chain (LHCDD) deposition disease. MIDD predominantly involves the kidney. Skin is the next common organ to be affected by HCDD, which presents as ACL. We report the case of a 40-year-old male who presented with ACL associated with LHCDD. The clinical features of ACL in the present case appeared prior to the development of clinical features related to LHCDD.

Clinically amyopathic dermatomyositis (CADM) is a subset of dermatomyositis (DM) that has conventional cutaneous manifestations of DM, but paradoxically, little or no muscle involvement. In 2005, a novel antibody was described in association with CADM – anti-melanoma differentiation-associated gene 5 (anti-MDA5). Patients with this serologic marker have a characteristic mucocutaneous phenotype consisting of skin ulceration among other signs. We describe the case of a 46-year-old woman with CADM, elevated anti-MDA5 autoantibodies, and unusual clinical features (livedo racemosa, florid acral edema) among the classical phenotype of MDA5 DM (arthralgias, ulcerations, panniculitis) and classical DM lesions (Gottron papules, heliotrope rash). The patients did not develop interstitial lung disease or internal malignancies and experienced a rapid response to prednisolone and intravenous immunoglobulins. After 2 years, she has no relapse of her cutaneous disease and continues 5 mg prednisolone and 2 g/kg kilogram of intravenous immunoglobulin every 3 months for maintenance. Our case highlights the clinical heterogeneity of CADM and underscores the importance of a comprehensive approach to DM patients. It was previously postulated that anti-MDA5 antibody could target vascular cells and compromise vascular function, the presence of livedo racemosa lesions, and MDA5 antibodies in a patient with negative thrombophilia workup, reinforce this idea. This is the first case, to our knowledge, of CADM with acral panniculitis and livedo racemosa.

Cutaneous mucinoses refer to disorders with abnormal accumulation of mucin in the skin. Mucin is an amorphous material that is a part of the extracellular matrix in dermis. Cutaneous mucinoses could be primary or secondary. The latter is associated with systemic disorders such as autoimmune diseases, diabetes mellitus, paraproteinemia, or altered thyroid function. Here, we report an adult female patient with trauma-induced cutaneous focal nodular mucinoses on left-sided scapular region. Histology showed replacement of collagen bundles by mucinous deposits in superficial and mid-dermis. Mucinous substance was present in peri-eccrine location on Alcian blue staining.