A Delphi consensus on the nomenclature and diagnosis of lichen planus pigmentosus and related entities

Background: Although well known in clinical practice, research in lichen planus pigmentosus and related dermal pigmentary diseases is restricted due to lack of consensus on nomenclature and disease definition. Aims and Objectives: Delphi exercise to define and categorise acquired dermal pigmentary diseases. Methods: Core areas were identified including disease definition, etiopathogenesis, risk factors, clinical features, diagnostic methods, treatment modalities and outcome measures. The Delphi exercise was conducted in three rounds. Results: Sixteen researchers representing 12 different universities across India and Australia agreed to be part of this Delphi exercise. At the end of three rounds, a consensus of >80% was reached on usage of the umbrella term ‘acquired dermal macular hyperpigmentation’. It was agreed that there were minimal differences, if any, among the disorders previously defined as ashy dermatosis, erythema dyschromicum perstans, Riehl’s melanosis and pigmented contact dermatitis. It was also agreed that lichen planus pigmentosus, erythema dyschromicum perstans and ashy dermatosis did not differ significantly apart from the sites of involvement, as historically described in the literature. Exposure to hair colours, sunlight and cosmetics was associated with these disorders in a significant proportion of patients. Participants agreed that both histopathology and dermatoscopy could diagnose dermal pigmentation characteristic of acquired dermal macular hyperpigmentation but could not differentiate the individual entities of ashy dermatosis, erythema dyschromicum perstans, Riehl’s melanosis, lichen planus pigmentosus and pigmented contact dermatitis. Limitations: A wider consensus involving representatives from East Asian, European and Latin American countries is required. Conclusion: Acquired dermal macular hyperpigmentation could be an appropriate conglomerate terminology for acquired dermatoses characterised by idiopathic or multifactorial non-inflammatory macular dermal hyperpigmentation

Dermoscope-guided Laser Excision of a Pilomatricoma – a Novel Surgical Procedure Performed in Primary Care Settings

Hypothesis:Dermoscope-guided laser excision is applicable for some cutaneous lesions seen in primary care, particularly those in body flexures or in regions with high blood perfusion.Summary:A male patient presented with an asymptomatic mass behind his left pinna. Polarised dermoscopy revealed signs compatible with malignancy. Excision was difficult owing to the location being concave and the region being one with hyper-perfusion.Dermoscope-guided laser excision was performed. The edge of the lesion and clear margins were marked via dermoscope-guidance. Laser incisions were made following the margins. Dermoscopy confirmed precision of the incision. Upon three laser-dermoscope cycles, the mass separated itself. Laser in coagulation mode achieved haemostasis.Dermoscope-guided laser excision was performed. The edge of the lesion and clear margins were marked via dermoscope-guidance. Laser incisions were made following such margins. Dermoscopy confirmed precision of the incision. Lesion incisions and dermoscopy were then reapplied. Upon three laser-dermoscope cycles, the mass separated itself. Laser in coagulation mode achieved haemostasis.Outcome:The histopathological diagnosis was a pilomatricoma. Healing was uneventful, with minimal scarring. There was no relapse one year post-operatively.Recommendation:Investigations on dermoscope-guided laser incision and other dermoscope-guided surgical procedures in primary care settings can beconducted to evaluate the outcomes of these procedures.

Pityriasis rosea--an update.

Recent controversies on the etiology, diagnosis and treatment have led to increased interest in pityriasis rosea (PR). We review these aspects of the disease. PR is universal. The incidence is around 0.68 per 100 dermatological patients, or 172.2 per 100,000 person-years. The prevalence in people aged between 10 and 29 years is 0.6%. The male to female ratio is around 1:1.43. Evidence on seasonal variation is conflicting, but there is no evidence that the incidence is dependent on mean air temperature, mean total rainfall, or mean relative humidity. Spatial-temporal and temporal clustering of cases of PR has been reported. The association of PR with human herpesvirus-7 infection is still controversial. Owing to the extreme high sensitivities of sequence-based detection methods such as polymerase chain reaction, novel criteria should be applied to evaluate the evidence. There is no evidence that PR is associated with other viral or bacterial infections. The role of autoimmunity in PR warrants further investigations. Many patients with PR have one or more atypical features. Application of validated diagnostic criteria may be helpful for atypical cases. The efficacy of macrolides, including erythromycin, in PR is still under evaluation. There is no evidence that antiviral agents are effective. The efficacies of ultraviolet radiotherapy and systemic corticosteroids are not well established. In managing a patient with PR, we should concentrate more on how the eruption is affecting the quality of life, i.e. the illness, rather than the extent and severity of the eruption, i.e. the disease.

Pityriasis rosea-like eruptions due to mustard oil application.

A young man employed in a construction company, presented with cutaneous lesions clinically simulating pityriasis rosea. Satisfactory and complete response to corticosteroids and antihistamines was followed by recurrence. Multiple recurrences within a short span of time arose a suspicion of alternative diagnosis. Site visit helped us to rule out occupational contact dermatitis. Further history taking revealed that he was recently using mustard oil for body massage. Subsequent patch testing confirmed contact hypersensitivity to mustard oil. Avoidance of the contact with mustard oil arrested appearance of further skin lesions. We stress the importance of taking a good history in clinical practice in disclosing a possible contactant.

Dermatitis recall during disulfiram therapy.

We report an alcoholic Indian man, a known case of contact dermatitis to nickel, who presented with recurrence at the same site, without having recent contact with nickel, following disulfiram therapy for his alcohol addiction.