Clinicodermoscopic and immunopathological profile of non-infectious non-eczematous inflammatory tattoo reactions: A retrospective study from a tertiary care centre of East India

Introduction: Tattoo-associated complications are on the rise due to the popularity of decorative tattoos in recent years. The exact pathogeneses of various tattoo reaction patterns are still unclear, and their dermoscopic details are sparsely reported. Aim: We aimed to retrospectively study the clinical, dermoscopic and immunopathological details of patients with non-infectious, non-eczematous inflammatory tattoo reaction patterns in a tertiary care centre of East India. Method: The clinical, dermoscopic and pathological details of all the patients who had non-infectious, non-eczematous inflammatory tattoo reactions were collected. In all the cases, immunohistochemistry was done for CD1a, CD3, CD4, CD8, FoxP3, CD20 and CD56. Results: A total of five patients of skin phototypes IV and V and six tattoo reactions were analysed. Five lesions had reactions at the site of a black tattoo, and one at the site of red tattoo. Clinically, the patients presented with erythematous or blue-grey flat-topped to verrucous papules and plaques. Dermoscopic features were dominated by a central white to pink-white structureless area, a peripheral grey-white to bluish-white structureless area, white scales, comedo-like opening with keratotic plugging, milia-like cysts and shiny white structures. Pathologically, except for one lesion that only showed a lichenoid reaction pattern in the red tattoo, all had a combination of reaction patterns. Immunohistochemistry showed increased epidermal and dermal Langerhans cells, predominantly CD8 positive T cells in the epidermis and dermis, sparse dermal B cells and CD4 positive T cells, reduced T regulatory cells and a complete absence of CD56 positive NK cells. Limitations: Small sample size was the limitation of the study. Conclusion: The clinical morphology and dermoscopy may not differentiate between various types of non-infectious non-eczematous inflammatory tattoo reactions. The immunological profile supports a delayed hypersensitivity reaction due to contact sensitisation to tattoo pigment, and CD8 positive T cells play a central role in executing various pathological reaction patterns, both in the epidermis and dermis

RASopathies: Dermatologists’ viewpoints

Ras/mitogen-activated protein kinase pathway dysregulation results in a group of disorders, collectively termed as RASopathies. Neurofibromatosis type 1, Noonan syndrome, Noonan syndrome with multiple lentigines, Noonan syndrome/loose anagen hair, Legius syndrome, Costello syndrome, cardio-facio-cutaneous syndrome and capillary malformation-arteriovenous malformation are the well- recognized RASopathies. These are characterized by multi-organ tumours and hamartomas. Some other features in common are facial dysmorphism, skeletal abnormalities, congenital heart disease, neurocognitive abnormalities and risk of various solid-organ and haematological malignancies. Some of the RASopathies are heterogeneous, caused by several gene mutations resulting in variations in phenotypes and severity ranging from mild to fatal. Significant phenotypic overlaps among different disorders, often makes it difficult to pinpoint a clinical diagnosis. Specific cutaneous manifestations are present in some of the RASopathies and are often the earliest clinical signs/symptoms. Hence, dermatologists contribute significantly as primary care physicians by identifying disorder-specific cutaneous lesions. However, diagnostic work-up and management of these disorders are often multidisciplinary. Confirmation of diagnosis is possible only by genetic mapping in each case. Genetic counseling of the patients and the affected families is an important component of the management. The aim of this review is description of cutaneous manifestations of RASopathies in the background of multi-system involvement to enable dermatologists a comprehensive and logical approach to work up and diagnose such patients in the absence of facility for specific molecular testing.

The strawberry tongue: What, how and where?

Morphological alteration of the dorsum of the tongue is seen in many disorders. These include alteration in color such as pallor and redness and surface alterations, giving rise to “balding,” “geographic tongue,” and the “strawberry tongue.” Iron deficiency anemia and vitamin B12/folic acid deficiency are the causes of balding/pallor and hyperemia (beefy red glossitis), respectively. Geographic tongue refers to a “map-like” appearance of the tongue seen in a host of disorders such as psoriasis and Reiter's disease. Strawberry tongue refers to the characteristic appearance of the tongue seen in certain disorders where it resembles the skin of a strawberry.

The strawberry tongue: What, how and where?

Morphological alteration of the dorsum of the tongue is seen in many disorders. These include alteration in color such as pallor and redness and surface alterations, giving rise to “balding,” “geographic tongue,” and the “strawberry tongue.” Iron deficiency anemia and vitamin B12/folic acid deficiency are the causes of balding/pallor and hyperemia (beefy red glossitis), respectively. Geographic tongue refers to a “map-like” appearance of the tongue seen in a host of disorders such as psoriasis and Reiter's disease. Strawberry tongue refers to the characteristic appearance of the tongue seen in certain disorders where it resembles the skin of a strawberry.

Anticoagulants in dermatology.

Anticoagulants are the cornerstone of treatment of venous thromboembolism associated with various medical conditions and surgical procedures. They act on different steps of the coagulation pathway and are broadly categorized into heparins, vitamin K antagonists, and inhibitors of thrombin and factor Xa. The classification is evolving as newer and better oral and parenteral anticoagulants are being added. Anticoagulants in dermatology are important not only for their therapeutic application in cutaneous thrombotic dermatoses such as livedoid vasculitis, purpura fulminans, superficial and deep venous thrombosis and others but also for their use in non‑thrombotic dermatoses such as lichen planus, recurrent oral aphthosis, chronic urticaria and several others. Further, the use of anticoagulants for any indication is associated with various adverse effects with dermatologic manifestations including specific reactions such as warfarin‑induced skin necrosis, heparin‑induced thrombocytopenia and anticoagulant‑associated cholesterol embolization syndrome.

Sensitive skin: An overview.

Sensitive skin is less tolerant to frequent and prolonged use of cosmetics and toiletries. It is self-diagnosed and typically unaccompanied by any obvious physical signs of irritation. With the change in lifestyle and also with increased opportunity to use many new brands of cosmetics and toiletries, there has been an increase in females complaining of unique sensation in their facial skin. Sensitive skin presents as smarting, burning, stinging, itching, and/or tight sensation in their facial skin. The condition is found in more than 50% of women and 40% of men, creating a sizable demand for products designed to minimize skin sensitivity. Good numbers of invasive and non-invasive tests are designed to evaluate and predict the sensitive skin. Management includes guidelines for selecting suitable cosmetics and toiletries in sensitive skin individuals.

Nails: Diagnostic clue to genodermatoses.

Nails are cutaneous appendages mostly involved in mechanical functions. However, nails may reflect presence of various systemic disorders evidenced by alteration of their shape, size, color or texture. Genodermatoses are multisystem disorders with cutaneous involvement. Many of the genodermatoses present with nail changes and some of these may be the clinical pointers to the diagnosis. Diagnostic clues to various genodermatoses derived from nail findings have been discussed.

Childhood vitiligo.

Childhood vitiligo is often encountered in dermatological practice. When present in infancy or early childhood, various nevoid and hereditary disorders are to be differentiated. In many cases, familial aggregation of the disease is seen and other autoimmune disorders may be associated. Segmental presentation is more common, and limited body surface area involvement is usual in this age group. Children with vitiligo often suffer from anxiety and depression because of their unusual appearance. Management of vitiligo in children is difficult as therapeutic options are restricted when compared to that in adult patients. Selection of treatment should be careful in these patients with the aim to achieve best results with minimal side effects as well as relieving patients' and parents' anxiety.

Current concepts in the management of bacterial skin infections in children.

Bacterial skin infections in children vary widely clinically, starting from mild superficial folliculitis to deep necrotizing fasciitis. The causative organisms are mostly Staphylococcus aureus and Streptococcus, with occasional involvement of Gram-negative organisms. Treatment of even the milder forms of bacterial skin infections is of importance because of the long-term morbidity associated with them. However, because of global emergence of resistant strains of bacteria, treatment of these conditions is becoming increasingly difficult. The current antibacterial resistance patterns in organisms causing skin and soft tissue infections and the problems encountered in their management in children have been discussed.

Clinicopathological study of itchy folliculitis in HIV-infected patients.

Background: Itchy folliculitis are pruritic, folliculo-papular lesions seen in human immunodeficiency virus (HIV)-infected patients. Previous studies have shown that it was impossible to clinically differentiate between eosinophilic folliculitis (EF) and infective folliculitis (IF). Also, attempts to suppress the intense itch of EF were ineffective. Aims: The present study is aimed at correlating clinical, histopathological and immunological features of itchy folliculitis in HIV patients along with their treatment. Methods: The present prospective study lasted for 36 months (September, 2005 to August, 2008) after informed consent, data on skin disorders, HIV status and CD4 count were obtained by physical examination, histopathological examination and laboratory methods. Results: Of 51 HIV-positive patients with itchy folliculitis, the predominant lesion was EF in 23 (45.1%) followed by bacterial folliculitis in 21 (41.2%), Pityrosporum folliculitis in five (9.8%) and Demodex folliculitis in two (3.9%) patients. The diagnosis was based on characteristic histopathological features and was also associated with microbiology confirmation wherever required. EF was associated with a lower mean CD4 count (180.58 ± 48.07 cells/mm 3 , P-value < 0.05), higher mean CD8 count (1675.42 ± 407.62 cells/mm3) and CD8/CD4 ratio of 9.27:1. There was significant reduction in lesions following specific treatment for the specific lesion identified. Conclusion: Clinically, it is impossible to differentiate itchy folliculitis and therefore it requires histopathological confirmation. Appropriate antimicrobial treatment for IF can be rapidly beneficial. The highly active antiretroviral therapy along with Isotretinoin therapy has shown marked reduction in the lesions of EF. Familiarity with these lesions may help in improving the quality of lives of the patients.

Histopathological study of pruritic papular eruptions in HIV-infected patients in relationship with CD4, CD8 counts.

Background: Pruritic papular eruptions (PPE) are common cutaneous manifestations in HIV-infected patients. Their frequencies, patterns and associated factors vary from region to region. There is no clear consensus on the etiology of PPE, the exact spectrum of the condition, the pathologic findings, or treatment. The present study is aimed at documenting the histopathological patterns of PPE, and their relation with CD4, CD8 counts in HIV-infected patients. Materials and Methods: The present study lasted for 12 months (September 2005 to August 2006). After informed consent, data on skin disorders, HIV status, CD4 and CD8 counts were obtained by physical examination and laboratory methods. Results: Of the 36 HIV-infected patients with clinical diagnosis of PPE, the most common histopathological patterns were prurigo simplex and eosinophilic folliculitis. The mean CD4 count of PPE was 186.49 cells/mm 3 with mean CD8 count of 619.60 cells/ mm 3 , and the CD4:CD8 ratio was 0.32. Patients with prurigo simplex had significantly lower mean CD4 counts (50.36 ± 30.67 cells/cmm 3 , P < 0.001) while in eosinophilic folliculitis, the mean CD8 counts were higher (1239.77 ± 402.30 cells/cmm 3 ). Conclusion: We conclude that histopathology helps in specifying the pattern of PPE and also indicates underlying immunosuppression and can be a marker of advanced HIV infection. Thus, correlation between the histopathology and immunology findings helps to know the disease process.

Nephrogenic fibrosing dermopathy.

An adult female patient on hemodialysis for chronic renal failure presented with large, brownish, and indurated plaques with bound-down skin on both lower limbs and abdomen along with difficulty in movement of the legs. Histopathological features revealed thick collagen bundles admixed with mucin and intercalating spindle-like cells characteristic of nephrogenic fibrosing dermopathy (NFD). Immunohistochemical study showed prominent CD68 positivity and weak CD34 positivity suggesting that the plaques were more than 20-weeks old. NFD in patients with chronic renal failure of unknown cause is a poor prognostic indicator. Early detection before the development of contracture and prompt treatment of NFD and underlying renal failure may reverse this disabling condition.