Isolated Wrist Drop Presenting as Acute Stroke: Rare Case Report with Review of Literature.

Isolated wrist drop is very unusual clinical presentation due to cerebral stroke. It is highly confused with peripheral neuropathy. However, timely detection of acute stroke as one of the causes of wrist drop is necessary as it changes the line of treatment and prognosis significantly. Here we are presenting a 62 year-old diabetic and hypertensive male patient who came with acute onset weakness of right hand. Initial Magnetic resonance imaging (MRI) of the brain showed hyperacute infarct in the splenium of corpus callosum. Magnetic resonance angiography (MRA) was normal. Repeat brain MRI on next day showed acute infarct at hand area of motor strip in posterior frontal region. The patient underwent intravenous thrombolysis and thereafter improved significantly. Isolated hand palsy is a rare presentation of stroke, often mistaken for peripheral lesion.

Can We Predict the Effectiveness of Intralesional Immunotherapy in Recalcitrant Warts?

Immunotherapy has been used for recalcitrant, large, and multiple warts, although it is difficult to predict which patient will respond. An open interventional cohort trial was conducted in 50 adult patients with recalcitrant multiple, nongenital warts in whom intralesional immunotherapy was given using the Mycobacterium welchii vaccine. The authors determined whether the wart resolution was dependent on the immune response. The response of various types of warts was also compared with the initial immune response. Complete cure was used as a treatment endpoint, which was defined as a lack of recurrence at follow-up of at least 6 months. The majority of patients had palmoplantar warts (54%). A total of 26 patients achieved a clinical cure. The high immune group achieved a higher complete cure rate (60%) as compared with the low immune group (20%) (P=.008; absolute risk reduction=.44; number needed to treat=3) with a fewer number of sessions (P=.004). This difference was most marked in palmoplantar warts (P=.04). Immunotherapy using M welchii is a useful modality in recalcitrant warts in patients who have a test site induration of ≥10 mm, but this does not affect the recurrence rates.

A prospective study comparing ultrapulse CO2 laser and trichloroacetic acid in treatment of Xanthelasma palpebrarum.

BACKGROUND: Xanthelasma Palpebrarum is a type of xanthoma which presents as cosmetic concern. OBJECTIVE: To compare the efficacy of 30% TCA and UpCO2 laser in XP. METHODS AND MATERIALS: Fifty patients with XP were categorized clinically into three groups. Patients in each group were alternately allocated to 30% TCA (Group A) and laser (Group B). TCA was applied weekly (maximum: 12 sessions), and laser sessions were given monthly (maximum: three sessions). The primary outcome measures were total patients cured, the number of sessions, and mean VAS at the end of treatment. The secondary outcome measures were total duration of treatment, side effects, and recurrence in follow-up (6 months) (P < 0.05 significant). RESULTS: In Group A, 14 of 25 and in Group B, 25 of 25 patients achieved complete cure (P < 0.05). The mean VAS was lower for Group A (patient: 4.56 vs. 5.36; physician: 4.64 vs. 5.44) [P < 0.05] with significant difference only for group III patients. Mean number of sessions was less with laser group (1.56 vs. 9.74), except in group I. There was no significant difference in pigmentary changes and recurrence. CONCLUSION: For clinically mild lesions, both TCA and laser are good options, but laser is a better option for severe lesions. Recurrence is a concern with both modalities.

Is frictional lichenoid dermatitis a minor variant of atopic dermatitis or a photodermatosis.

CONTEXT: Frictional lichenoid dermatitis. BACKGROUND: Frictional lichenoid dermatitis (FLE) is an entity that is probably under diagnosed and has been variably associated with either friction and/or atopy with a distinctive seasonal variation. AIMS AND OBJECTIVES: To study correlation of FLE with UV index and to assess its association with atopic dermatitis. MATERIALS AND METHODS: A cross sectional analysis of children with FLE was done, over a period of 6 years in two tertiary hospitals. A detailed history and examination was done to assess the features of atopic dermatitis. The number of cases seen per month was compared with the mean monthly UV index. Two-tailed significance tests using Pearson's coefficient of correlation and T-test were used to interpret the data. (P < 0.05). RESULTS: One hundred seventy-four patients were studied using the UKC criterion 17.2% of the patients had AD while xerosis (40.3%) was the predominant cutaneous finding. The number of patients seen in summer was more than in winter (P < 0.05) but there was no statistical difference between the cases in winter and spring. There was a significant correlation of the number of cases per month with UV index (P = 0.019). Almost 42% of patients gave a history of recurrence. CONCLUSIONS: FLE is probably not associated with atopic dermatitis and is likely to be related to the ambient UV index though a larger cohort with meticulous follow up may be needed to draw a final conclusion. STATISTICAL ANALYSIS USED: The Pearson's coefficient of correlation was used for comparing the cases per month with the UV index. The tests of hypothesis used included the paired T-tests. F-test of variance, Welch test, Wilcoxon rank sum test and the Kolmogorov-Smirnov Test. P < 0.05 was considered significant.

Nasal septal ulceration.

Nasal septal ulceration can have multiple etiologies. Determining the exact cause depends on who the consulting specialist is, who could either be the ENT surgeon or the dermatologist. The common causes are infections (tuberculosis, leprosy, leishmaniasis), vasculitis (Wegener's granulomatosis and Churg-Strauss syndrome), and lupus erythematosus. Traumatic causes and malignancy can also be seen in tertiary referral centers. The diagnosis often requires thorough investigations and multiple tissue specimens from various sites, and in chronic cases, a suspicion of lymphoma should be considered. Apart from disease-specific therapy, a multidisciplinary approach is required in most cases to tackle the cosmetic disfigurement.

Optimal management of common acquired melanocytic nevi (moles): current perspectives.

Although common acquired melanocytic nevi are largely benign, they are probably one of the most common indications for cosmetic surgery encountered by dermatologists. With recent advances, noninvasive tools can largely determine the potential for malignancy, although they cannot supplant histology. Although surgical shave excision with its myriad modifications has been in vogue for decades, the lack of an adequate histological sample, the largely blind nature of the procedure, and the possibility of recurrence are persisting issues. Pigment-specific lasers were initially used in the Q-switched mode, which was based on the thermal relaxation time of the melanocyte (size 7 µm; 1 µsec), which is not the primary target in melanocytic nevus. The cluster of nevus cells (100 µm) probably lends itself to treatment with a millisecond laser rather than a nanosecond laser. Thus, normal mode pigment-specific lasers and pulsed ablative lasers (CO2/erbium [Er]:yttrium aluminum garnet [YAG]) are more suited to treat acquired melanocytic nevi. The complexities of treating this disorder can be overcome by following a structured approach by using lasers that achieve the appropriate depth to treat the three subtypes of nevi: junctional, compound, and dermal. Thus, junctional nevi respond to Q-switched/normal mode pigment lasers, where for the compound and dermal nevi, pulsed ablative laser (CO2/Er:YAG) may be needed. If surgical excision is employed, a wide margin and proper depth must be ensured, which is skill dependent. A lifelong follow-up for recurrence and melanoma is warranted in predisposed individuals, although melanoma is decidedly uncommon in most acquired melanocytic nevi, even though histological markers may be seen on evaluation.

Management of chronic paronychia.

Chronic paronychia is an inflammatory disorder of the nail folds of a toe or finger presenting as redness, tenderness, and swelling. It is recalcitrant dermatoses seen commonly in housewives and housemaids. It is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. Repeated bouts of inflammation lead to fibrosis of proximal nail fold with poor generation of cuticle, which in turn exposes the nail further to irritants and allergens. Thus, general preventive measures form cornerstone of the therapy. Though previously anti-fungals were the mainstay of therapy, topical steroid creams have been found to be more effective in the treatment of chronic paronychia. In recalcitrant cases, surgical treatment may be resorted to, which includes en bloc excision of the proximal nail fold or an eponychial marsupialization, with or without nail plate removal. Newer therapies and surgical modalities are being employed in the management of chronic paronychia. In this overview, we review recent epidemiological studies, present current thinking on the pathophysiology leading to chronic paronychia, discuss the challenges chronic paronychia presents, and recommend a commonsense approach to management.

Lipoid Proteinosis: a case report in two siblings.

Lipoid proteinosis was first reported by Urbach and Wiethe in 1929. It is also known as hyalinosis cutis et mucosae or Urbach-Wiethe disease. It is a rare autosomal recessive disorder and characterized by the infiltration of hyaline material in the skin, oral cavity, larynx, and internal organs. Lipid proteinosis presents early in life. Hoarseness develops in infancy. The classic sign is beaded eyelid papules along the lid margin, also known as 'Monilform Blepherosis'. In India about 30 cases have been reported to date. We report the following case because of its rarity in the Indian literature.

A promising split-lesion technique for rapid tattoo removal using a novel sequential approach of a single sitting of pulsed CO(2) followed by Q-switched Nd: YAG laser (1064 nm).

BACKGROUND: Laser tattoo removal conventionally uses Q-switched (QS) lasers, but they require multiple sittings, and the end results depend largely on the type of tattoo treated. In pigmented skin, due to the competing epidermal pigment results, laser results in tattoo are slow and inadequate. OBJECTIVE: To evaluate the efficacy of a combined use of ultrapulse CO2 and QS Nd:YAG (1064 nm) laser in the treatment of tattoos in Indian skin. MATERIALS AND METHODS: A split-lesion trial was carried out in five patients, with the left side of tattoos receiving the QS Nd:YAG (1064 nm) and the right side, a sequential combination of Up CO2 and QS Nd: YAG at 6 weeks interval with a maximum of six sittings. Outcome assessment was carried out by a blinded assessor using standardized photography. An assessment of physician improvement score, side-effects score, and patient satisfaction score was taken during and at the end of the study. RESULTS: There was a statistically significant improvement on the combination side(physician improvement score -3.7 vs. 1.87: P = 0.0019) which occurred earlier with fewer sittings (1.7 vs. 6). There was no statistically significant difference in the side effects. CONCLUSION: A combination of an Up CO2 laser with QS Nd: YAG laser is a promising tool for rapid and effective removal of blue-black/blue amateur tattoo in pigmented skin.

Reticulate pigmentary disorders.

Reticulate pigmentary disorders is a term that is loosely defined to include a spectrum of acquired and congenital conditions with different morphologies. The presentations vary from the reticular or net like pattern to the" freckle like" hyper and hypopigmented macules that are usually restricted to the true genetic "reticulate" pigmentary disorders. There is little clarity on this topic and related terms, in major dermatology textbooks. Hence, to harmonize the different entities we feel that the term "mottled pigmentation" could be used to include reticulate pigmentary disorders (acquired and congenital), dyschromasias and the disorders with a reticular pattern. The genetic reticulate pigmentary disorders can also be classified according to the gene loci which in the majority of cases are localized to keratin 5/14. A more useful clinical method of classification is based on the regional distribution, which includes facial, truncal, acral or flexural types. In this review we will largely focus on the inherited reticulate pigmentary disorders.