Intra-Operative Dermoscopy in Assessment of Melanonychia and as a Guide for Biopsy.

BACKGROUND AND AIMS: Melanonychia can be a manifestation of benign or malignant pathology and often poses a diagnostic challenge on clinical examination. Even with distinguishing dermoscopic features (nail plate), it can be quite difficult to determine the nature of pigmentation as complete assessment of nail bed and matrix is still not possible. Intraoperative dermoscopy (IOD) can serve as a useful tool to appreciate the bed and matrix changes. The aim here is to study the intraoperative dermoscopic features in patients with melanonychia and correlate with histopathology. METHODS: 20 consecutive patients with melanonychia were recruited. Inclusion criteria was melanonychia of sudden onset, progressive nature, irregular width/color/symmetry on dermoscopy, positive Hutchinson sign, solitary nail involvement or associated nail dystrophy. Preoperative dermoscopy was performed and recorded. Patients were planned for nail matrix biopsy, during which IOD was performed over nail matrix and bed after removal of the nail plate. Images were recorded and analyzed and correlated with the histopathology. RESULTS: Out of 20 patients, 12 were females and 8 males. On IOD-histopathological correlation, 2 patients were found to have melanoma of the nail unit, 5had nail lichen planus, 9 had benign melanocytic nevi, and 4 had fungal melanonychia. IOD revealed fine, parallel and regular lines of pigmentation localized to proximal nail bed and matrix in all patients with benign melanonychia, while dark thick bands with irregular borders, dots, globules, streaks and structureless areas in the two patients with melanoma. Fungal melanonychia revealed an unremarkable nail bed and matrix on IOD. CONCLUSION: Intraoperative dermoscopycan help in determining the nature of melanonychia and obviate the need to perform biopsy in certain cases. It can also aid in delineating the most suitable site for biopsy, along with grossly assessing the extent of involvement in case of malignancy.

Successful Limb Salvage in a Case of Advanced Long-Standing Eumycetoma of the Foot Using Adjunctive Local Amphotericin B Delivery Through Bioabsorbable Beads.

Mycetoma is a chronic, granulomatous infection mainly involving the foot and is caused either by bacteria (actinomycetoma) or fungi (eumycetoma). Eumycetoma is notoriously resistant, posing a therapeutic challenge. There are no specific treatment guidelines but generally a combination of systemic antifungals and local surgical treatment is the accepted standard. Advanced unresponsive lesions generally require amputation. We present a case of eumycetoma of 15-year duration with extensive involvement of foot including bones. Patient had been advised amputation from various tertiary care centers but we decided to give a limb salvage trial. The patient underwent soft tissue debridement along with oral antifungal therapy. Additionally, amphotericin B-impregnated bioabsorbable beads were inserted locally into the bony cavities to supplement the treatment. There has been no recurrence till date. This case is reported in view of successful limb salvage in an advanced eumycetoma case with an unprecedented use of adjunctive local antifungal delivery.

Atypical Presentation of Sweat Dermatitis with Review of Literature.

Sweat dermatitis is a peculiar kind of irritant inflammatory dermatoses occurring due to prolonged exposure of retained sweat over the skin. It is commonly seen in hot and dry climates like tropics during summer months due to thermal stress. Typically, parchment paper or cellophane paper like scaling is seen over occluded areas of back, shoulder, and other areas. Here we have reported a varied presentation of sweat dermatitis in the form of its coexistence with miliaria rubra (impending to thermal burn). Further we have also observed co existing pityriasis versicolor and sweat dermatitis where the former has prevented the development of latter. Till date there is very little discussion on this condition, so we have tried to provide a concise review about sweat dermatitis along with its classical to atypical presentation with special emphasis on dermoscopy.

Allergic contact dermatitis to phenylephrine eye drops in an infant.

Ophthalmic medications used for diagnostic or therapeutic purposes are common causes of allergic contact dermatitis around the eyes. We report a case of periocular allergic contact dermatitis due to tropicamide and phenylephrine eye drops in a 1-year-old infant.

Evidence-based Review, Grade of Recommendation, and Suggested Treatment Recommendations for Melasma.

Treatment of melasma is known to be less satisfactory, often incomplete, and relapse is frequent. Although many treatment options are available, they are either known to be unsafe on long-term use or their long-term safety profile is unknown. Patients often use various drugs, even topical steroid-based preparation without any medical supervision for long period of time, making the skin unsuitable for many of the drugs available. Thus, there has been gross disparity among the treating physician about what drugs and what regimen are best suitable for various categories of melasma patients and in different situations. With this background, numerous newer drugs, mostly combinations of some proprietary molecules or even unknown plant extracts, have flooded the market for the management of melasma. Information on efficacy or safety of these products are almost unknown. Studies on Asian people, especially Indian population, are far less commonly available. Therapeutic guideline for use on Indian patients with melasma is almost missing. Extrapolation of data from Caucasian people for use on Asian people may not be scientifically justifiable because Caucasian and Asian people are known to have inherent difference in their response as well as tolerance to the drugs used for melasma. With this background, we have extensively evaluated, following a strict, scientifically designed protocol, all the available studies on melasma management till May 2016 and prepared this document on level of evidence, grade of recommendation and suggested therapeutic guideline for melasma as per the method proposed by Oxford Centre of Evidence-Based Medicine. Various ethical, social, logical, regional, and economic issues in the context of Indian and similar populations were given due importance while preparing the suggested therapeutic recommendation.

Guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis: An Indian perspective.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous adverse drug reactions with a high morbidity and mortality that require immediate medical care. The various immunomodulatory treatments include systemic corticosteroids, cyclosporine, intravenous immunoglobulin, cyclophosphamide, plasmapheresis and tumor necrosis factor-α inhibitors. AIM: The ideal therapy of Stevens-Johnson syndrome/toxic epidermal necrolysis still remains a matter of debate as there are only a limited number of studies of good quality comparing the usefulness of different specific treatments. The aim of this article is to comprehensively review the published medical literature and frame management guidelines suitable in the Indian perspective. METHODS: The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) assigned the task of preparing these guidelines to its special interest group on cutaneous adverse drug reactions. The group performed a comprehensive English language literature search for management options in Stevens-Johnson syndrome/toxic epidermal necrolysis across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for keywords (alone and in combination) and MeSH items such as "guidelines," "Stevens-Johnson syndrome," "toxic epidermal necrolysis," "corticosteroids," "intravenous immunoglobulin," "cyclosporine" and "management." The available evidence was evaluated using the strength of recommendation taxonomy and graded using a three-point scale. A draft of clinical recommendations was developed on the best available evidence which was also scrutinized and critically evaluated by the IADVL Academy of Dermatology. Based on the inputs received, this final consensus statement was prepared. RESULTS: A total of 104 articles (meta-analyses, prospective and retrospective studies, reviews [including chapters in books], previous guidelines [including Indian guidelines of 2006] and case series) were critically evaluated and the evidence thus gathered was used in the preparation of these guidelines. RECOMMENDATIONS: This expert group recommends prompt withdrawal of the culprit drug, meticulous supportive care, and judicious and early (preferably within 72 h) initiation of moderate to high doses of oral or parenteral corticosteroids (prednisolone 1-2 mg/kg/day or equivalent), tapered rapidly within 7-10 days. Cyclosporine (3-5 mg/kg/day) for 10-14 days may also be used either alone, or in combination with corticosteroids. Owing to the systemic nature of the disease, a multidisciplinary approach in the management of these patients is helpful.

Primary cutaneous angioplasmocellular hyperplasia.

Angioplasmocellular hyperplasia is a rare clinical condition with blood vessel proliferation and a reactive plasma cell infiltrate. To the best of our knowledge fewer than 20 cases of cutaneous angioplasmocellular hyperplasia have been published in English literature. We report a case of a 65-year-old man who presented with a long standing asymptomatic flesh colored ulcerated nodule on the back. Histopathological examination revealed a dermal vascular proliferation with polyclonal plasma cell infiltration. A diagnosis of angioplasmocellular hyperplasia was established. This entity is rare and we would like to emphasize the importance of clinico-pathological correlation to differentiate it from various other conditions of cutaneous plasma cell infiltration.

Treatment of severe refractory erythema nodosum leprosum with tumor necrosis factor inhibitor Etanercept.

Erythema nodosum leprosum (ENL) is a common complication of lepromatous leprosy. Some patients unresponsive to conventional, first-line therapeutics develop recurrent, recalcitrant ENL. Here, we report a case of severe refractory ENL that was successfully treated with Etanercept. Biologics may be considered as therapeutic alternatives in management of severe, recalcitrant ENL.

Serum Homocysteine and Total Antioxidant Status in Vitiligo: A Case Control Study in Indian Population.

BACKGROUND: Oxidative stress is considered as an initial pathogenic event in melanocyte destruction. These free radicals are scavenged by antioxidants, whose sum of activity in serum is measured by total antioxidant status (TAS). In addition, homocysteine (Hcy) may mediate melanocyte destruction via increased oxidative damage. However, previous studies investigating these parameters in vitiligo provide equivocal results. AIMS: To study and compare serum Hcy and TAS levels in vitiligo patients with controls and also to correlate these parameters with the various disease characteristics. The present study further looked into any correlation between serum Hcy and TAS in vitiligo. MATERIALS AND METHODS: A case control study was conducted on 82 vitiligo patients and 83 controls aged 18-45 years after excluding factors which could potentially alter serum Hcy or TAS levels. Disease characteristics were studied and blood samples were obtained for measuring serum Hcy and TAS levels. RESULTS: TAS levels were lower in vitiligo patients than controls (1.79 ± 0.51 vs. 2.16 ± 0.63 mmol/L; P < 0.001) and had a negative correlation with disease activity (r = -0.410, P < 0.001). However, serum Hcy levels were comparable between vitiligo patients (18.68 ± 9.90 µmol/L) and controls (20.21 ± 13.39 µmol/L) (P = 0.406). No significant correlation was found between serum Hcy and serum TAS levels. CONCLUSIONS: Serum TAS may be further investigated to establish its role as biomarker for vitiligo since its levels also correlate with disease activity. However, serum Hcy may not be a reliable marker in Indian population probably because of differences in dietary habits.

Shampoo and Conditioners: What a Dermatologist Should Know?

Dermatologists many a times encounter questions from patients and even colleagues asking about how to keep their hair looking clean, healthy and beautiful. Therefore, familiarity and a basic knowledge of the available hair care products will help them to guide their patients properly. A shampoo not only provides the cleaning of the scalp skin and hair as its primary function, but in addition also serves to condition and beautify hair and acts as an adjunct in the management of various scalp disorders. To achieve this, various ingredients in the correct proportion are mixed to provide a shampoo which is suitable for individuals having different hair types and hair need. Among the ingredients that go into the making of a shampoo are detergents, conditioners, thickeners, sequestering agents, pH adjusters, preservatives and specialty additives. Hair conditioners are designed to improve hair manageability, decrease hair static electricity and add luster. They are used in several ways depending upon the state of hair and requirement of the individual. This article attempts to put forward the basic and practical aspects regarding use of these products.

Cutaneous tuberculosis due to multidrug-resistant tubercle bacilli and difficulties in clinical diagnosis.

This report describes 6 HIV-negative patients including 5 children with scrofuloderma and an adult with lupus vulgaris, out of a total of 303 cases of cutaneous tuberculosis seen during a 4½-year period, who showed a positive tuberculin test and granulomatous histopathology, but failed to respond to first-line antitubercular therapy. They were suspected to have multidrug-resistant infection as no other cause could be ascertained. Tissue aspirate or biopsy was sent for histopathology and culture. Mycobacterium tuberculosis was isolated from the aspirate in three patients and sputum in one with associated pulmonary tuberculosis. Drug susceptibility tests showed that all isolates were resistant to rifampicin and isoniazid, and one each additionally to streptomycin and ethambutol, respectively. In two, culture was unsuccessful. All were administered second-line antitubercular drugs. Clinical improvement was appreciable within 2 months as weight gain, and regression of ulcers, swellings and plaques. Two completed the recommended 24 months of therapy. Multidrug-resistant cutaneous tuberculosis should be suspected in patients with no response to first-line drugs, with clinical deterioration, and where other causes of treatment failure are not forthcoming. Owing to poor isolation rates on culture and low sensitivity of molecular tests, in such cases, a trial of second-line anti-tubercular drugs may be justified for a reasonable period of 2 months. Where facilities permit, culture and drug sensitivity tests should be done before starting treatment. Culture positivity is better from aspirated material.

Mycosis fungoides: Positron emission tomography/computed tomography in staging and monitoring the effect of therapy.

A 58-year-old woman, diagnosed as a case of mycosis fungoides (MF), underwent [18F]-fluoro-D-glucose positron emission tomography/computed tomography (FDG PET/CT) examination. The study revealed intense FDG uptake in a large ulceroproliferative right thigh lesion, indurated plaques in the chest wall and left thigh, along with multiple sites of cutaneous involvement, axillary and inguinal lymphadenopathy. The patient underwent chemotherapy with CHOP regimen, radiotherapy for the right thigh lesion, along with topical corticosteroids and emollients for the disseminated cutaneous involvement. Repeat [18F]-FDG PET/CT study performed a year later, showed near complete disease regression specifically of the ulceroproliferative lesion and indurated cutaneous plaques, no change in lymphadenopathy, and a subtle diffuse progression of the remaining cutaneous lesions. A multidisciplinary approach to the diagnosis, staging and treatment of MF has long been suggested for optimizing outcomes from management of patients with this disease. This case highlights the potential role of incorporating PET/CT as a single modality imaging technique in the staging and assessment of response to therapy.

(18)F-FDG PET/CT in an unusual case of cardiac plexiform neurofibromatosis.

Cardiac involvement is rare in neurofibromatosis 1 (NF 1). Very few cases of cardiac masses in this entity have been documented in the world literature. We present the F-FDG PET/CT findings in a rare case of cardiac plexiform neurofibromatosis.

Multifocal tuberculosis verrucosa cutis.

Tuberculosis Verrucosa Cutis (TBVC), a verrucous form of cutaneous tuberculosis, occurs from inoculation of tubercle bacilli into the skin of a previously sensitized patient with moderate to high degree of immunity. This disease is now rare in western countries and in India; the incidence of cutaneous tuberculosis has fallen from 2% to 0.15%. However two recent studies from the Indian subcontinent have reported the prevalence of cutaneous tuebrculosis as 0.7% (Varshney et al) and 0.26% (Patra et al) This case is reported to demonstrate the indolent and extensive nature of tuberculosis verrucosa cutis in an immunocompetent individual and to highlight the importance of histopathology and empirical antitubercular therapy as an adjunct diagnostic tool.

Porokeratosis ptychotropica: a rare variant of porokeratosis.

BACKGROUND: Porokeratosis, a well recognized disorder of keratinization, is known to have several clinical variants. This report describes a rare variant characterized by verrucous plaques. METHODS: An adult male presented with a slowly progressive verrucous plaque on the gluteal region that was resistant to conventional therapy. Careful inspection revealed a keratotic ridge at the plaque border leading to the diagnosis. RESULTS: Histopathology showed the presence of multiple cornoid lamellae confirming the diagnosis of porokeratosis ptychotropica. CONCLUSIONS: Porokeratosis ptychotropica is a rare variant of porokeratosis with fewer than 25 cases described in the literature. This report is to highlight the importance of considering this particular entity in the diagnosis of genitogluteal plaques, especially those not responding to conventional modalities.